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10 <br /> APPLICATION FOR PEMIT <br /> SAN JOAQUIN LOCAL HEALTH! DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON; CA , <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISS <br /> UI=D <br /> ' yy' (Complete in Triplicate) <br /> l 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 incompliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/ um <br /> r:Local Health District. , p p and the Rules and Regulations of the San Joaquin <br /> Joh Address''. <br /> CityLot Size <br /> PM . <br /> Owner's Name Address ` <br /> Phone <br /> t •t Coritractor's Name <br /> nse No: /.l/ 00 1 y <br /> "TYPE OF WELL/PUMP: Phone <br /> -;'TYPE NEW WELL ❑ WELL REPLACEMENT ❑T DESTRUCTION ❑ <br /> s PUMP INSTALLATION'❑ 3 f, <br /> SYSTEM.REPAlR;❑ OTHER ❑ <br /> .DISTANCE TO NEAREST: SEPTFC TANK <br /> — .---:!.SEWER' . ,LiN,ES . <br />! ° .DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE.WEL.L z 'OTHER WELL <br /> -INTENDED USE PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA' 'CONSTRUCTION SP,ECIFfCATIO" ' <br /> Industrial D Open Bottom ❑ Manteca Dia. of Well,Excavation = E <br /> ❑ Domestic%Private ❑ Gravel Pack;•_ Dia. of Welf Casing <br /> Tracy `:�7ype;of Casing ' <br /> / , I ❑ Public ;. " Specifications <br /> ❑ Other C7.De�ta 'Depth of Grout Seal'"" - ,� <br /> r D Irrigation T s. �: Type of Grout <br /> --Approx Depth•^'❑ Eastern �' ' + <br /> Surface Seal;Installed by <br /> ' Repair Work.bone. D Type of,Pump, H P <br /> Well Destruction, 11m <br /> t Well Diaeter .Se <br /> 2:siafee'Wo?k'bone <br /> i. ng Material (top 50') ' <br /> Dep"tai ;Filler.Material*{below �r ; <br /> TIPE.OF SEPTIC WORK: NEW INSTALlAT <br /> REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> lnstallatlon-'willserve: Rest encs Commercial ti Othe <br /> r. Number of iiving,units: .Number of bedrooms 'i �• <br /> -' ,. <br /> t Character of soil to a depth of,3 feet: <br /> STIC TANK ' �; r`p . )+ype/Mfg '� 4� Water tableTdepth <br /> s Capicity-��' No, Compartments <br /> PKG. TREATMENT PLj. a l <br /> s Distance to nearest INefl Method of Disposal <br /> t ' # `"`'� :Foundation, Property Line <br /> LEACWiNG LINE "" No. &•Len <br /> gth of lines: <br /> FfLTER BED i otal length/size <br /> =—;❑ Distance to nea►est: Well Foundat o _ Property,Line <br /> SEEPAGE PITS Depth Slze' <br /> r k Number <br /> SUMPS' Distance rto'nearest: Well F <br /> DISPOSAL PONDS p � xl`oundatlon - Property Line <br /> hereby"'certify that J;have <br /> prepared this and that the Work wrll,be'done+n accofdance with;San Joaquin county ordinances, state laws, and r <br /> ;rules and regulations'of the San Joaquin,Local.Health District.- h r., <br /> -Home owner or licensed agentssigriature certifies the following: "I certify that u1 the rfo�mance of the work for which this <br /> employ any person in such manner as to:become subject to,workman's aompensatian`laws+gf California:"Contractors hiring orsub contractin Isihall <br /> tu�e <br /> certifies the following:"I certrfy;that iri tK6 performani a of.the.wark.for which this perritit rs rcif Cii, f shall em to g` g <br /> tion laws of California: . , A Y.persons subject to workman's cbmpensa- <br /> The^applicant us a re uir d in t <br /> ,.• q pectlons.Comple drawing b rse side. <br /> 'Signed v+- <br /> y, Title <br /> Date: <br /> FOR DEP 4 NT USE'ONLY <br /> Application"Accepted.by <br /> Date Area <br /> Pit-or Grout Inspection.by `�` Date v <br /> Final Inspection'by Date G `� <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca, 823-7104 ❑ Tracy 8356365 <br /> Applicant- Return all copies to:-Environmental Health Permit/Services'1601 E. Hazelton Ave,,:P.O. Box 2009, stk., CA 95201 <br /> FEE 1 � <br /> INFO AMOUNT DUE 1= AMOUNT,REMITTED; CASH RECEIVED BY GATE <br /> -i3 - - PERMIT`NO. �f- <br /> + EH 13.24IRII 10/83l �...r F_ .• # <br /> EH'14-28 f <br />