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3 <br /> ,q . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQ.UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ' (Complete in Triplicate)` <br /> - � <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 /> ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Coun <br /> Local Health District. f <br /> / City S 'Lot Size PM <br /> Job Address } <br /> Owner's Name 4- iv,��J� /%�� /'� Address Phone <br /> 1 Address -�/ d IAZZ License No. ZL4-Phone <br /> Contractor I <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION I 2 g):�pAAZOEAlIPSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Manteca Dia. of Well Excavation <br /> EJ Industrial LJ Open Bottom Specifications <br /> C1 Domestic/Private ❑ Gravel Pack L3 Tracy Type of Casing p <br /> ❑ Public <br /> ❑ Other ❑.Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _—Approx.'Depth d Eastern Surface Seal Installed by p SUB <br /> f H P State Work Done <br />[ Repair Work Done ❑ Type of Pump <br /> Well Destruction d Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> ithin m permitted if public sewer is 00 <br /> available Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth ro . <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. <br /> Method of Disposal S <br /> C1f <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING UNE E3No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> - SEEPAGE PITS - ❑ Depth +� Size - <br /> x Number'-'' e <br /> SUMPS ❑ Distancelto nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ t <br /> application and that the work will be donee in accordance with Sen Joaquin county ordinances state laws, and <br /> I hereby certify that I have prepared this <br /> rules and regulations of the San Joaquin Local Health District. ., 1 <br /> Home owner or licensed agent's signature certifies the following: "I certify that'in the performance of the work for which this peri s'issutin I shall not <br /> r employ any person in such manner as to become subject to workman's compensation laws of California:" Contractor's hiring or suli-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 applicant ust call or all a wired inspections. Complete drawing on reverse ide:��;} <br /> Title: 'v `� r Date: <br /> + Signed X � <br /> €f t <br /> FO EPARTMENT USE ONLY 3 <br /> Date Area <br /> 4 Application Accepted by <br /> k E r Date [ C/ <br /> Pit or Grout Inspection by ate Final inspection by <br /> —Additional-Comments.- -- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 <br /> —Additional-Comments.- El 823 7104 ❑ Tracy &35 6385 <br /> mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environi <br /> - I CK �RECEIVED BY DATE PERMIT NO. <br /> _FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO iL.� ii m� <br /> + EH 13-24IREV-i/a 5Y {� s- 4+,5 75 <br /> EH 1426 -- '� r <br />