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_ r <br /> a !, AP�CATION FOS PERMIT <br /> A <br /> ,� ;. <br /> �Si�►7 JOQUIN'=`LOCAL HEALTH DISTRIE'T <br /> ^,; :.. <br /> 1601"E 'HAZEU'!ON AVE., STOCKTON, CAS, <br /> TelepFrone 1209) 466 6781 , <br /> PERMIT,EXPIRES 1`aIEAR FROM DATE ISSUED <br /> (t6p6plete in Triplicate) <br /> r�permit to construct and/or install the work herein described.This application is <br /> Application is hereby made to the San Joaquin'Local Health;DistrfcE;.fo p <br /> made in 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 District. <br /> C �1 �.- fav t City TLot Siz <br /> eio <br /> Job Address C w�i e <br /> I� Phone <br /> Address Shoop �t j <br /> Owner's Name aL <br /> w Phone6 C7 <br /> �Address - License No. --� <br /> Contractor DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT kO; y <br /> 1 . <br /> PUMP INSTALLATION ❑ <br /> SVST'EM REPAIR ❑ OTHER ❑ <br /> SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK.�� PITS/SUMPS <br /> AGRICULTURE WELL OTHER WELL <br /> FOUNDATION —� __. . t 4 sb � <br /> TYPE OF WELL PROBLEM AREA C4NSSRUCTI4N SPECIFICATIONS r !r <br /> INTENDED USE �— Dia. of Well Excavation Dia. of Well Casing <br />�- ❑ Industrial ❑ Open Bottom ❑ Manteca Specifications <br /> © Trac Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack y Depth of Grout Seal Type of Grout <br /> ❑ Other ❑ Delta <br /> El Public ce Seal Installed by <br /> ❑ Irrigation ---Approx. Depth. ❑ Eastern Surfai <br /> H P State Work Done' `1 <br /> Repair Work Done ❑ Type of Pump — ` Sealing Material (tap 50') 13 Well Destruction L3 Well Diameter �. <br /> Depth Filler Material (Below 50'1 rmitted'rf public sewer is G <br /> available within 200 feet.! ! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ available❑ DESTRUCTION ❑ (No septics em 4 <br /> r ice. <br /> Installation will serve: Residence„'�',-Commerciaitx_-•-Others' —� N i <br /> . � <br /> Number of living units Number o�bedrooms Water table depth <br /> S Y <br /> j Character of soil to a depth of 3"feet: �� Capacity No. Compartments Z <br /> SEPTIC TANK 14 Type/Mfg �� Method of Disposal <br /> PKG. TREATMENT PLT. ❑ N,� /O Property Line <br /> Distance to nearest: Well Foundation <br /> ❑ No. &-Length of lines _ '* r Total length/size i <br /> LEACHING LINE Foundation"Lf� ` Property Line <br /> FILTER BED '❑ Distance to nearest: Well-�11.— - P <br /> Number <br /> SEEPAGE PITS ❑ Deptli 'r O Size <br /> ' <br /> SUMPS ❑ Distance to nearest: Weil <br /> Foundations Property Line s <br /> DISPOSAL PONDS ❑. ./}- <br /> y v _ <br /> I hereby certify that I have preparewith San Joaquin county ordinances, state-laws, an <br /> d this application and that the work will be done in accordancedance <br /> I shall not <br /> rules and regulations of the San Joaquin Local Health following: <br /> lio ing <br /> Home owner or licensed agent's <br /> torbecome subIjectolto Workman's <br /> rtcompensation laws oof California.r Contractor'st. lhir ng othis rsub-conrmit is st actng signature <br /> _. employ any person in such <br /> certifies the following: ••1 certify that in the performance of the work for�ich�his•peYmit is issued,L shall employ persons subject to workman's compensa- <br /> tion laws of California." _ <br /> omplete drawing on reverse side. <br /> The appGca must cal all required inspections. C <br /> _. Date: 4 <br /> Title: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> le <br /> DateA,_ Area 1 3 j <br /> k!4*e <br /> Application Accepted b Data <br /> Pit or Grout Inspection <br /> Date Final Inspection by <br /> o-_s <br /> Additional Comments: ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> ❑ Stk 466-6751 ❑ Lodi 369-3621 Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Health Permit/Servioe5 1601 E. Hazelton Ave., P.O. Box 2009. <br /> I CK RECEIVED BY DATE PERMIT"N0. <br /> FEE AMOUNT'DUE AMOUNT REMITTED Q <br /> INFO <br /> +EH 13-24(REV.1/55) <br /> EH 14-26 - <br />