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. a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA t'' W, <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDt��AL GAS <br /> (Complete in Triplicate) - E?,'01! <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 /> nty Ordinance No.549 for sewage or No. 1862 for weillpump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Cou <br /> Local Health District. ' <br /> �e� � <br /> �� O a 7A6Ot R-[�C_lu.>r'f A f City Lot Size PM <br /> Job Addres <br /> Owner's Name +` r1t�� Address Phone <br /> 7 <br /> Contractor Address License No r { Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION. Iq� SYSTEM REPAIR Ll OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> _,DIST) TO NEAREST:-SEPTIC TANK. - .� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r <br /> Dia. of Well Casing <br /> industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> T e of Casin Specifications <br /> ..Domestic/Private ❑ Gravel Pack ❑ Tracy = Yp g Type of Grout -� <br /> t`1 Public L7 Other n Delta x Depth of Grout Seal <br /> I I Irrigation :Approx.�Depth - i I Eastern ,e Surface Seal installed by - Q <br /> Repair Work Done ❑ Type of Pum!D,4- �-�" H-P• State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> 1 <br /> Depth 1 Filler Material [Below 50'1 �f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (I REPAIR IADDITION l I DESTRUCTION I I <br /> available septic <br /> system <br /> ithin m rented if public sewer is <br /> Installation will serve:-Residence_` Commercial.— Other <br /> Number of living units: Number of bedrooms <br /> + Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ "s Method of Disposal <br /> r - - —Pro ert _Line <br /> Distance,to nearest:���Welt'� Fouridation � P Y (1 <br /> LEACHING LINE ❑ No. & Length of lines <br /> A s 4i Total length/size <br /> FILTER BED ❑ Distancetonearest: Well""" Foundation Property Line <br /> I <br /> I. <br /> SEEPAGE PITS I 1 Depth !I Size Number <br /> SUMPS Cl Distance'to neatest: Well `Foundation -­ProperN Line <br /> DISPOSAL PONDS ❑ t <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 taws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> - rt that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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 4he 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 applica it for all re fired inspections. Complete drawing on reverse side. <br /> f Title: Date: `' r <br /> i Signe X <br /> I 0 DEPARTMENT USE ONLY <br /> r c <br /> I Date Area <br /> Application Accepted b <br /> T2�_ <br /> Pit or Grout inspection by <br /> Date Final Inspection by Date �� • <br /> Additional Comments: <br /> El Stk 4&6-6781 El Lodi 369-3621 ❑ Manteca 523-7104 ❑ Tracy 835-6385 <br /> + Applicant- Return all copies to: Envi nmenml Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> t <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> ' INFO A OUNT DUE AMOUNT REMITTED CASH rr!!,, } <br /> +.EH 13-24 1REV.+i ri s+ -D 1 <br /> EH 14-26 r <br />