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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 I-YEAR FROM DATE ISSUED n,r <br /> (Complete in Triplicate)' <br /> Application is hereby made to the San Joaquin Local Health District for a permittoconstruct 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 /> Job Address �.`T. <br /> ra... i <br /> 1L <br /> t 1r..w;► City _ Lot Size <br /> " PM <br /> 1 � � � <br /> Owner's Name i q R Y <br /> - Address/�Z�.`] L( -Phone Z—710 <br /> F <br /> Contractor Address e29Q <br /> TYPE OF WELL/PUMP: •License No. 0 <br /> 9/3 Phone <br /> NEW WELL WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LiDISTANCE TO NEAREST: SEPTIC TANK 1 �OTHEl��R ❑ <br /> SEWER LINE ES _,��_ DISPOSAL FLD.-rJ __ <br /> FOUNDATION! PROP. LINE <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> # <br /> INTENDED USE '' TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca bio. of Well Excavation 4 <br /> .Domestic/Private 1- /°� Gravel Pack Dia. of Well Casing <br /> ❑ Public � Tracy Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation � Type of t <br /> J��Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done C7 Type of Pump H p <br /> Well Destruction ❑ Well Diameter ) Sealing Material {top 50'} State Work Done <br /> . <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve:° Residence i l,1 <br /> Commercial� Other � W <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: O <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity " <br /> PKG. TREATMENT PLT. 71No. Compartments <br /> Distance to nearest: Wep Method of Disposal <br /> I Foundation <br /> Property Liner <br /> LEACHING LINE ❑ No. & Length of f lines I <br /> FILTER BED f Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> t <br /> SEEPAGE PITS ;❑ Depth °� � Size <br /> Number ) <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS E3Property.Line <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San'Joaquih 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 the work for which this permit is issued, I 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 antOust call for all reved o pections. Co plate}drawing on ever side. <br /> Signed .J -- ., <br /> Title; <br /> f /� �5�3 OR DEPA TMIEN USE ONLY ' t <br /> ppli ation Accepted by, Z � � <br /> Date Area r <br /> Pit or Grout Inspection by Date ,,�L� <br /> r Final Inspection by Date`"` *` <br /> Additional Comments: t 11 <br /> C] Stk 466-6781 ❑ Lodi 369-3621 t ❑ Manteca •823-7104 ❑ Tracy 835-538,5 - <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> � <br /> INFO AMOUNT DUE AMOUNT REMITTED <br /> C ;RECEIVED BY - DATE PERMIT"NO. <br />+ EH 13-24(REV.1/85) <br /> EH 1426 Ll 3, _ <br />