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T <br /> APPLICATION FOR PERMIT <br /> 'LOCAL HEALTH DISTRICT <br /> SAN JOAQUIN <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA l` <br /> Telephone (209) 466-67$1 . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> x (Complete in Triplicate) application is <br /> eb made to the San Joaquin Local Health District for a permit to construct ell/puand/oinstall the Rules awork.hnd <br /> R described.This <br /> Application is hei Y oa uin Co Ordinance No.549 for sewage or No. 1862 for welllpump and the flutes and Regulations of the San Joaquin <br /> made in compliance with San J q i <br /> Local Health District. ( PM 1-- <br /> r S City � S of Size <br /> .fob Address `� �� � Phone <br /> �ddress Sr i <br /> Owner's Name / Phone <br /> License No.�--- <br /> AddressDESTRUCTION a <br /> Contractor WELL REPLACEMENT ❑ <br /> ;NEW WELL El � OTHER <br /> TYPE OF WELLIPUMP: SYSTEM REPAIR ❑ PROP. LINE <br /> PUMP 1N5TALLATION ❑ DISPOSAL FLO. <br /> SEWER LINES OTHEfl WELL PITSISUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK _ — AGRICULTURE WELL I <br /> FOUNDATION ..�---- <br /> INTENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> d Manteca Dia. of Well Excavation Specifications <br /> p Industrial ❑ Open Bottom Type of Casing <br /> ❑ Gravel Pack ❑ Tracy Type of Grout <br /> C] Domestic/Private n pelta Depth of Grout Seal <br /> fl Public Ll Other Surface Seal Installed by <br /> Approx. Depth I astern State Work Done <br /> k k I Irrigation l EI-I•p, <br /> Repair Work Done Type of Pump -- Sealing Material (top 501 <br /> Well Destruction ❑ Well Diameter _ <br /> Depth r Filler Material (Below 50'1 (No septic system permitted if public sewer is <br /> € vailable within 200 feet.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.I. REPAIR/ADDITION l l pESTRUGTIIs <br /> Installation will serve: Residencef� <br /> Commercial , Other <br /> Number of living units: Number of bedrooms — Water table depth <br /> Character of soil to a depth of 3 feet: Capacity_� <br /> No. Compartments <br /> SEPTIC TANK X TypelMfg Method of Disposal <br /> F PKG. TREATMENT PLT. aFoundation�-- <br /> Property Line <br /> Distance to nearest: Well <br /> } Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Foundation Property Line 1� <br /> FILTER BED ❑ Distance to nearest: Well <br /> ��— <br /> 4 Number <br /> r41 Depth Size <br /> SEEPAGE PITS rFoundation Property Line -� <br /> SUMPS ❑ Distance to nearest: Well <br /> DISPOSAL PONDS ❑ fi <br /> = I hereby certify that I have prepared this application)h dpthat <br /> s atc�he wank will be done in accordance with San Joaquin county ordinances, state Laws, and <br /> rules and regulations of the San Joaquin Local Health <br /> 'the fto workman`s compensation laws of California." Contractor's <br /> h ubjecrt to workman'scompensa- <br /> Home owner or licensed agents signature certifie the following: "!certify that In the performance of the work for whiciring h this permit is issued, 1 signature <br /> she not <br /> employ ant person in such manner as to become subject <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,l she employ <br /> tion laws of California." <br /> r The appli ant must call for all requ' ed inspections. Complete drawing on reverse side. Date: <br /> r Title: <br /> X <br /> Signed <br /> R DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by _..Date 2 r <br /> Date .Final Inspection by <br /> Pit or Grout Inspection by 7 <br /> X61 7 <br /> Additional Comments: Manteca 804 ❑ Tracy 835- <br /> 23-715365 5tk., CA 95201 <br /> ❑ Stk 466-6761 ❑ Lodi 369-3 1 El <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> CK DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CASH <br /> RECEIVED BY <br /> IN <br /> . EH 13-24(REV.5/H 51 r o o cH �✓` <br /> EH 14-28 - <br />