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af: <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <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 /> made H 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 Districtlf? . <br /> r <br /> Job Address 7 A <br /> City Lot Size <br /> Owner's!Name � F Address <br /> ' S•..�Phane � <br /> Contractor's Name _ License No. 17 <br /> TYPE OF WELL U Phone <br /> NEW WELL ❑ WELL RE CEMENT G DESTRUCTION C] <br /> PI IMP INSTALLATION � - #- <br /> S EPAIR Lii OTf jER ❑ <br /> DISTANCE TO NEAREST: 5�, ,ice IHfVK �" <br /> — SEWER LINES DISPOSAL FLD . PROP. LINE, <br /> FOUNDATION r' r — <br /> _ AGRICULTURE WELL ,.•, t -,THER WELL .¢ _ PITS/SUMPS` <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial IT Open Bottom ❑ Manteca Dia. -- Well Excavation <br /> r ❑ Domestic/Private © Gravel Pack ❑ Tracy Type of Casing f Dia. of Well Casing <br /> ._Y. ❑ Public m '� - - -- ,. — Specifications <br /> ❑ Other Delta Depth of Graut Seal �� "" "—" - <br /> ❑ Irrigation Type of gout_ f <br /> _AApprox. Depth Eastern Surface Seal Installed by <br /> Repair Work 045, 4b ypp "Pump H.P. State Work Done <br /> Desiinn�y7 ih ameter Sealing Material {top 5011 , <br /> • ^�4� D p Filler Material (Below 50') ; <br /> TYPE OF INORfr NEW iNSTALLATION ❑ PA ADDITION DESTRUCTION ❑ (No septic system ermitted i u <br /> P I sewer!si <br /> i available within 200 feet <br /> Installation will serve: Residence ` <br /> Comm rcial_ Other <br /> Number of living units:—/— 'Number of'berooms 4' - <br /> Character of soil to a depth of 3 feet: ( ;. <br /> SEPTIC TANKTypWater table depth - <br /> e/Mfg ' <br /> PKG. TREATMENT PLT. ❑ {. Capacity_-�_ No. Compartments <br /> ( Method of Di�osa! <br /> Distance to nearest""-Well -Foundation �� Property Line , <br /> LEACHING LINE No. & Length of lines <br /> ,� ,�, Total length/size <br /> FILTER BED ❑ Distance to nearest:fWe!! <br /> aun.�ation Property Line <br /> SEEPAGE PITS ❑ Depth r' <br /> p SF a �. �� 3=, Number t. , ♦ x t <br /> SUMPS istance to nearest: !i oundation l { <br /> Property Line <br /> S N <br /> I hereby certify that I have prepared this application and int the ork w!ll be d e !n arc ordance with San Joaq�ionrdinances, state laws and <br /> rules and regulations of the San Joaquin Local Health D€str!ct. g <br /> Home owner or licensed agent's signature certifies the fo in de <br /> employ an -9 the performance of the work for which this permit is issued, I shill not <br /> P Y Y Person in such manner as to become subjbct -Work a c .k on -of California."Contractors hiring or subfMk-an". <br /> ib-Ature <br /> certifies the following:"I certify that in the performance o he wo for which this permit is issued, I shall em to <br /> tion laws of California." ���iiiiii p Y p6rsons subject to compensa- <br /> The applicant must cal! or all require inspectio s. Comete d wing on revs side. <br /> Signed <br /> Date: Y/ <br /> OR EPARTMENT USE ONLY W <br /> Application Accepted by ~' <br /> OWN, te�,,,, a ©�' <br /> Pit or Grout Inspection b Date Fin Inspection by }_'o�L l' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca -7104 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/ ices 1601 Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT pUE 9 AMOUNT REMITTED C SH—' <br /> INFO <br /> W <br /> +EH 13-241REV,10/831 <br /> EH t426 - <br /> a <br />