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T <br /> APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL i ON.AVE., STOCKTON, CA <br /> Telephone (209) 466`-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED' I; <br /> {Complete in Tri Cate).. <br /> cation is <br /> At nd/or install the work herein pplication is hereby made to the SanCounty Joaquin <br /> ordinance lNo.549 for sewage or Health istrict for a rNo.-1862 for well/pump and the Ryles and Regu atians of the Sandescrib .This Joaquin <br /> made in compliance with San Joaquin t <br /> L'ocal'Health District. r ,, /rr A�' F M L <br /> " City ! Lot Size <br /> ".lob Address A , <br /> AddAdd rer Q" Phone <br /> •Owner's Name � ' <br /> ss <br /> Contractor Address <br /> icense N4. yl Phone <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER C1PUMP INSTALLATION ❑ DISPOSAL FLD.� PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK fJ SEWER LINES' ` <br /> FOUNDATION -- -AGRICUL-TL1RE WE'LL _=- OTHER WELL <br /> r+ <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of We11 Excavation <br /> Tracy Type of Casing Specifications ' <br /> Domestic/Private. Gravel Pack > TypV.of Grout <br /> � ❑ Public <br /> E3 Other f <br /> ❑ Delta Depth of Grout Seal <br /> :0,.Irrigation _--Approx. Depth ❑ Eastern Surface Seal Install by <br /> Repair Work Done ❑. Type of Purn <br /> H.P. State Work•Done <br /> a Weil Destruction ❑ Well DiameterSealing Material (top 601) J' <br /> A Depth Filler Material (Below 5(1'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11REPAIR/ADDITION C1 DESTRUCTION El (No <br /> septi cystem <br /> avaithin 200 feet.) if public sewer is f <br /> { lnstaikation"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: No. Compartments <br /> SEPTIC TANK "❑ Type/Mfg Capacity - <br /> - Method of Disposal <br /> 1 `PKG. TREATMENT PLT. ❑ Pro Line <br /> Distance to nearest; Well Foundation Pert1+ <br /> Total length lsize <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER,BED • ❑ Distance.to nearest: Well Foundation <br /> ... : <br /> rSEEPAGE PITS ❑ Depth " Size Number <br /> sumps _ _ EIDistance.to nearest: Well. , ._ Found­ationProperty�Line_,_.�--- <br /> DISPOSAL PONDS a <br /> 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 the work for which this permit is issued, k shah not <br /> employ any person in such manneras to become subject to workman's compensation laws of California."Contractors hiring or sub contracting si§nature <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 appticantfnuat call for all requ' d inspections. amplete drawing on reverse side. <br /> i <br /> Title: Date: <br /> Sidned <br /> l <br /> FOR DEPA IUIENT USE ONL �rO r D <br /> i Date Q Area <br /> Application Accepted by, <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date„�u <br /> Additional Comments: <br /> ❑ Stk 488$781 ❑ Lodi 369-3621 ❑ Manteca 823-7144 ❑ Tracy 83546 M <br /> .Applicant: Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 <br /> FEE; RECEIVED BY DATE PERMIT"N0. <br /> z. INFO' AMOUNT DUE AMOUNT FtEMITTED <br /> + EH 13-24(REV.3/65) ��7 * @� <br /> EH 1428 <br />