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• APPLICATION FOR PERMIT • <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> S� //�Jdl� /U cam. City drd�Lot Size PM <br /> Job Address ^/ �� ��� �/ <br /> Owner's Name <br /> l f ✓IMC, IA lsl�CJ�+— Address 7 /T�r`n P""' ��N�pu Phone: <br /> 41 tiJ Q�a Phone <br /> Contractor's Name License No. <br /> TION <br /> TYPE OF WELUPUMP; - NEW WELL ❑ WELL REPLACEMENT ❑ DESTR Q . . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR'- <br /> OTHER ❑ <br /> - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well using <br /> ❑ Industrial Li open Bottom ❑ Manteca is. of Well Excavation <br /> Specifications <br /> '�Damestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout. <br /> 11 Public ❑ Other 11 Delta Depth of Grout Seal <br /> ❑ Irrigation --Approx. DepthQ/ Eastern Surface Seal Installed by N <br /> Repair Work Done Type of Pump ._ilcl01 H P J •— State Work Done � <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available within with ne200 feet.), if public sewer is <br /> Installation will serve: Residence— Commercial—'.Other <br /> Number of living units:_ Number of bedrooms p <br /> Water table depth t <br /> Character of soil to a depth of 3 feet: No. Compartments l <br /> SEPTIC TANK ❑ Type/Mfg Capacity. <br /> Method of Disposal <br /> PKG. TREATMENT PLT.❑ - <br /> Property Line <br /> Distance to nearest: Well Foundation <br /> >Y <br /> Total length/size. <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth . Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify teat in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lam of California." <br /> The applican at II for all r red' pecY ns. Complete drawing on reverse side.— T42 itle: p>p 5 Date:. <br /> Signed _ <br /> FOR DEPARTMENT USE ONLY - <br /> 00, Date Akea. U <br /> Application Accepted by <br /> Date Final Inspection Iw <br /> Pit or Grout Inspeati y I <br /> 11n:Ito 7u+,-w - /.cv S-�� O w 4-..r� <br /> Additional Comments: /—T L s !y <br /> 835-6395 <br /> J4�r <br /> ❑ Stk 488.8761 ❑ Lodi 369-3621 Cl Manteca 823-7104 E3 Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk CA 95201 <br /> FEE CK RECEIVED BY DATE PERMITNO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH ,. <br /> + EH 1324(REV.10/69) 3 S . o.�. 1�A <br /> EH 1426 <br />