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N.- <br /> 4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA i <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />` (Complete in Triplicate) <br /> all <br /> . This <br /> cation is <br /> Application is heieby made to the SanJoaquin <br /> nLocalHe lth District 549 for sewage or for a it to construct <br /> a ldpu r atnd th <br /> made in compliance with Rules and the work herein <br /> Regulations of the San f Joaquin <br /> San Joaquin County <br /> Local Health District. <br /> Lot Size PM <br /> Job Address City' <br /> �M Phone ` <br /> j 1�►1 Address <br /> I` Owner's Name ( <br /> 3�W o Phone �r V <br /> l tf1w.1 License No. <br /> Contractor <br /> lr'11Address DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: ow <br /> NEW WELL C7 WELL REPLACEMENT ❑ _ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR D OTHER ❑ <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTURE WELL OTHER WELL PkT51SUMPS <br /> 4 INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ industrial L1 Open Bottom , E Manteca Dia. of Well Excavation Specifications <br /> i Type of Casing <br /> i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> E I Other i t Delta Depth of Grout Seal <br /> � FI Public t � - <br /> I 1 Irrigation —.-Approx. Depth l lEastern Surface Seal Installed by <br /> iH P State Work Done <br /> } Repair Work Done ❑ Type of Pump <br /> Sealing Material Stop 50'I <br /> I Well Destruction ❑ Well Diameter g F <br /> kk Depth Filler Material iBelow 50'1 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION 1No s <br /> vailablerw thin 200 feetsystem ��led if public sewer is <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: No. Compartments ^ '" <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ _#_ <br /> Distance to nearest: Well Foundation Property Line <br /> 1 Total length/size <br /> LEACHING LINE ❑ No. & Length of lines property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation t <br /> Number <br /> _ <br /> -SUMPS <br /> PITS t 1 Depth Size ` � Property Line <br /> SUMPS CI Distance to nearest: Well Foundation <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 Di§trict. <br /> Home owner or licensed agent's signature certifies the following: "I certify that 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 laws of California." <br /> The appli nt must c I for a uired insaections. Complete drawing r verse s' e.y <br /> Title: Date: <br /> Signed X <br /> FOR DEPARTMENT USE ONLY <br /> Data � Area <br /> t Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by f7ate� <br /> t Additional Comments: <br /> ElStk 466-6781 ❑ Lodi 369.3621 C1 Manteca 823-7104 C3 Tracy 835-6365 Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> FEE <br /> AMOUNT'DUE AMOUNT REMITTED RECEIVED BY DATE PERMITNO. <br /> •e"i. INFO <br /> + EH'13-24IREV.I/x51 S <br /> 14 � 1 <br /> EH t4-28 <br />