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' <br /> APPLICATION FOR PERMIT ` <br /> SAN JOAQUIN�LOCAL HEALTH DISTRICT" <br /> 1601 E. HAZELTON AVE,, STOCKTON, CA ' <br /> Telephone (209) 466-6781 f <br /> PERMIT EXPIRES 1 .YEAR FROM DATE ISSUED ' <br /> (Complete,in Triplicate) I <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 in compliance with San Joaquin County Ordinance No.549 for sewage or No. IOU for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job.Address .r+ <br /> City �rG <br /> —� � Lot Size Ply <br /> Owner's Name =r Tex�-5AddressLL /6� <br /> f - Phone_ <br /> Contractor's Name yT/�i�ir Som/ License No. '��%.- %/ <br /> TYPE OF WELL/PUMP: <br /> - NSW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE "!'" <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑Industrial ❑ Open Bottom 15 Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel ❑.Tracyr, Type of Casing <br /> Pack _ Dia. of Well Casing <br /> _ � . <br /> ❑ Public ❑ Other ❑ Delta - - Specifications <br /> Depth of Grout Seal {6.1 <br /> ❑ Irrigation + ---Approx. Depth ❑ Eastern Surface Seal Installed by Type of Grout �-.t� t <br /> Repair Work Done ❑ Type of Pump H p "Y <br /> Well Destruction ❑ Well Diameter State Work Doe <br /> Sealing Material (top 50') ; <br /> Depth — --:— Filler Material (Below 50') t r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAfFI/ADDITION ❑ DESTRUCTfON ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_' available within 200 feet.) <br /> Other <br /> Number of living units: Number of bedrogms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth f C <br /> fel Type/Mfg ��rT Capacity <br /> PKG. TREATMENT PLT. j--- No.Compartments <br /> EJ <br /> (F1 <br /> Distance to nearest: Well yFoundMethod of Disposal <br /> ation �S Property Line—212 <br /> LEACHING LINE, .( No. & Length of lines a <br /> FILTER BED ' Total length/size O <br /> ❑ Distance to nearest:2 Well� Foundation Property Line -5 <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ❑ DiNumber <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> El <br /> I 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, 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 applicant must call,.16r all required inspections. Complete drawing on reverse side. <br /> Signed �C <br /> Title: c <br /> = Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by pate Oj <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by K @3te� <br /> Additional Comments: _I'll <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> ,835 5Z0 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA ��'� �" �! <br /> r, 7 j c /l <br /> FEE AMOUNT DUE <br /> AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY E 40 <br /> PERMIT`NO. <br /> Eh 13-24(REV,f0/83) <br /> EH 1426 � � Od �.....tI�Z: <br />