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i <br /> APPLICATION FOR PERMIT <br /> " SAN JOAQUIN LOCAL"HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 r�t, : • L. ° <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 10 <br /> (Corrlplete in Triplicate) �p,Y98;7 { <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wor % l�� GVbq.pT, hi J' �tjgn is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or,No. 1862 for well/pump and the Ryles anal f��illJ/�tKV� in <br /> Local Health District. u u �,t V J <br /> Job Address i City Lot Size PM <br /> Owner's Name 4 Address hone '� d <br /> Contractor Address t License No. Phone <br /> TYPE OF WI=LL/PUMP: NEW WELL ❑ WELL RtPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR i& OTHER ❑ <br /> ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE. <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Diaffof Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed by if <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Jtop 501 � <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> ' available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other I <br /> i <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: '1 ' Water table depth i <br /> SEPTIC TANK ❑ Type/Mfg V i Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well a Foundation Property Line <br /> '.I s <br /> LEACHING LINE ❑ No. & Length of lines -Total•lerfgth/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i 6-) <br /> E <br /> SEEPAGE PITS ❑ Depth -Size f Number <br /> _ SUMPS ❑ Distance to nearest: Well Foundation � operty Line_ <br /> ❑ <br /> DISPOSAL PONDS Rt b <br /> I hereby certify that I have prepared this application and that the work;will be done in accordance with San Joaquin county ordinarices, state laws, and F <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."Contractors hiring or sub-contracting signature I <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must scall li required inspections. Complete drawing on reverse side. ► <br /> Signed X Title: Date: <br /> FOR DEP RTMENT USE ONLY' <br /> Application Accepted by Date /a ' Area / <br /> Pit or Grout Inspection by ...�� Date — Final Inspection by CLIi Date <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE }� AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> c '\ �/JJ�^7 p � <br /> + EH 13-241REV.1/85) " `�V `"t 18 D S-_ j-04�r g� <br /> EH 1428 <br />