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APPLICATION FOR PERMIT <br /> � <br /> 0-5 ' <br /> R e vw.._-� <br /> SAN JOAQUiN,L•OCAL;HEALTH DISTRICT <br /> 1601 E.,HAZEO.N•'AVE., STOCKTON, CA <br /> Telephone QC 1 466-6781 <br /> PERMIT EXPIKES-1.YEAR FROM. DATIt 1SSUED,;;i,i . � ydt It, 41+161LO <br /> `r, :. i�'.,, .t ;� si i� r�.. ,v�1,,Y,• siCofnplete,in''Triplicate) <br /> Application is hereby made to the San Joaq,in Local Health District for a permit to construct andlor install the work herein described. This application is , <br /> made in compliance with„San Joaquin County Ordinance No:-549 forsewage or No.1662-far well/pump:and the!Ruies andRegulations of the San,Joaquin <br /> Local Health District r, <br /> 1. <br /> City ,Lot!Size,, PM <br /> Job Address <br /> _ <br /> q <br /> Owner's Name ddress Phone- .,- � <br /> Contractor's Name ^ License No.,. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP..LINEI k k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL_ PITS/SUMP.S <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open'8ottom - ❑ Manteca Dia. of Well Excavation Dia.�of Well Casing <br /> ElDomestic/Private ❑.Gravel Pack ❑ Tracy Type of Casing -Specifications <br /> ❑ Public ❑:Other ❑ Delta l.Depth of Grout SeaType of Grout h <br /> ❑ Irrigation __ARPfox: Depth CI Eastern Surface Seal Installed by <br /> Repair Work Done LlType of Pump H.P. State Work Done t ^” 1 Lh <br /> •`mss./ � � F <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 11`f I <br /> Depth Filler Material (Below 50') <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION,❑ (No septicygystem permitted if:publi�_sewer is <br /> - - availablerwithin•200 feet.) <br /> Installation will serve: Residence— ,Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: # /N Water table depth � { <br /> SEPTIC TANK E Type/Mfg Capacity No. Compartments <br /> PK . TREATMENT PLT. ❑ f Method of Disposal i <br /> ,d i- <br /> 19U4L Distance to nearest:,wWell Foundation 3Z �-! Property Line i <br /> LEACHING LINE ❑ No. & Length of lines �, -' i Total length/size ' L f <br /> I 4 <br /> FILTER BED ❑—''Distance for nearest: PropertLine <br /> SEEPAGE PITS t ❑ -Depth ��' f Size: I Number z <br /> SUMPS ❑ Distance to nearest. Well "'Foundation Property Cane <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepared this application and that the�workwill be done in accordance witl''San Joaquin county ordinancesj_'state laws, and <br /> rules and regulations of the,San-Joaquin L•'ocal Health,Distnct <br /> I[ <br /> Homeowner or licensed-agent's signature�eertifies thill.fbllbwmg,.'I certify.that in tl e,performance of the work for which this permit is issued, I shall not i <br /> employ any persomin-such-mariner as to subiedt;t6workman's compensatiori.laws.of California."Contractors hiring orsub contracting signature <br /> certifies the following:'T certify that,in the performance'of the•work for vdfiich this permit is issued,I shall.employipersons subject to workman's compensa r <br /> tion laws of California." <br /> L The applicant m II for all required inspections.•Complete drawing on reverse side. + <br /> Dated <br /> - Signed- <br /> FOR DEPr�FRTMENT USE ONLY <br /> i. <br /> Date rl Area <br /> Application Accepted by y ,moi <br /> Date Final inspection bice. Date <br /> Pit or Grout Inspection b �__,• <br /> ' Additional Comments: �r <br /> i .♦- .i. iw- j"F _- - 'ILS`_ 1. <br /> ❑ Stk 466-6781 ❑ L i 3ea3621 ElMa`nteca 873-7104 ' 'O Tracy --835-6385 I 1! <br /> Applicant- Return all copies to: Envuorimental Health`k�mitlServices 1601 E. Hazelton Ave., 0.0. Box 2009,Stk.; CA 952 E y{ <br /> FEE" AMOUNT DUE AMOUNT REMITTE[] j_ K RECEIVED t3Y ' F BATE s~ PERMIT"NO ^'^ <br /> INFO CASH f <br /> 5 ` <br /> + EH 1324 IREV-101831 <br /> EH 14-26» - <br />