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APPLICATION FOR PERMIT <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 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 /> ul <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 /> Q��� <br /> Local Health District. t <br /> Q Lot Size PM — <br /> Job Address — <br /> `_ Phone <br /> �„ _�_ Address _ <br /> Owner's•Neme I. <br /> Phone <br /> License No. _ <br /> Contractor's Name, DESTRUCTION D <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR ❑ OTHER G 7 <br /> + PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS D� of Well Casing <br /> I-] IndustrialC Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Tracy Type of Casing— _ <br /> D Domestic/Private D Gravel Pack Grout Seal TDepth of Groype of Grout <br /> G Other :1 Defta _�...._..-��....:� _ <br /> El Public - _ <br /> Approx. Depth G Eastern Surface Seal Installed by <br /> D Irrigation State"Work Done <br /> Repair Work Done D Type of Pump H.P. _ <br /> Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter' <br /> Depth Filler Material (Below 60'1 <br /> TYPE OF SEPTIC WO11 I'll RK: NEW INSTALLATION REPAIR-/ADDITION 0—DES '❑ available lwith n8200 feet.) <br /> In itted if public sewer is <br /> Installation will serve: Residence._Commercial.___ Other <br /> Number of living units: Number•of bedrooms Water table depth_ <br /> Character of soil to a depth,of 3 feet: =' ^' 4 <br /> .ems. r_��w� r Capacity t No. Compartments <br /> SEPTIC TANK y)< .Type/Mfg •1 Method of Disposal { <br /> PKG- TREATMENT PLT. C ._„_�,;�. �,��.� -� ��y� ' .1 ' <br /> i Foundation�d _ Property Line�sL-- <br /> Distance to nearest: <br /> Weil 1Sd�L— <br /> ! Total length <br /> LEACHING LINE ❑ No. & Length of lines _ Property Line <br /> FILTER BED �( Distance to nearest: Well Foundation - p rty <br /> Size Number <br /> ( SEEPAGE PITS ❑ Depth property Line <br /> SUMPS O Distance to nearest: Well Foundation <br /> DISPOSAL PONDS D <br /> I 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 that in the performance of th” Contractors hiring <br /> or sub contracting signature <br /> e work for which permit is issued, I shall not <br /> t employ any person in such manner as to become subject to workman's compensation laws of California. <br /> ` the performance of the work for which this permit is issued,1 shall employ persons subject to workmen's compen <br /> certifies the following: "I certify that Insa- <br /> E tion laws of California." <br /> f The appiica must call for all required inspections. Complete drawing on reverse side. 3Q'P <br /> 4 9G..(L , Date: 3 <br /> 54 <br /> Signed <br /> Title:A'�'f <br /> Fq PARTMENT USE ONLY <br /> I Date Area <br /> Application Accepted b <br /> Pit or Grout Inspection y <br /> Date Final Inspection b. Date <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 D Manteca 8237104 D Tracy 835 6386 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazefton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 691,L K <br /> FEE RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE]=! CASH1Nfo+ EH 13-2.iREv. 10/83) <br /> EH 1426 <br />