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APPLICATION FOR PERMIT t" <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 � <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA i <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1nAa— <br /> (Complete in Triplicate) <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> Ci of Size ,S pM <br /> f r <br /> Owner's Name Address ALr. ��✓_ <br /> Phone <br /> Contractor Address C—%SIe rev/ �_ <br /> License No. Phone <br /> TYPE OF WELL/PUMP; <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LI <br /> DISPOSAL PROP. LINE <br /> FOUNDATION AGRICULTUR ELL Opiell WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS UC SPECIFICATIONS ry <br /> C1Industria! ❑ Open Bottom ❑ Manteca Dia. Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private <br /> ❑ Gravel Pack 11 Tracy ype of Casi <br /> 1-1Public ❑ Other Specifications <br /> ❑ Delta Depth of Grout al <br /> ❑ Irrigation ---AType of Grout <br /> pprox. Depth ❑ ern Surface Seal Install d by <br /> Repair Work Done ElType of Pump H.P. <br /> Well Destruction ❑ Well DiameterState Work Done <br /> Seating Material (top 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 /> Installation will serve: Residence_ Commercial i Other available within 200 feet.] <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> Type/M#g Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Weft Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS Depth Size <br /> Number �1!11011 ill !!ill <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 regulation San Joaquin Local Health District. <br /> Homeowner or I' ensed a ant'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 per on in su manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fol wi that int performance of the work for which this permit is issued,I shall employ <br /> tion laws of C 'f p Y Persons subject to workman's compensa- <br /> tion <br /> icant If f s tions. mplete drawing on reverse side. <br /> Signed ��jj��yy <br /> Title: �— <br /> FOR DEPARTMENT USE ONLY �b"'C51 <br /> Date: <br /> Application Accepted by Date 3'Y7 —89 <br /> Ar a <br /> Pit or Grout Inspection Date Final Ins <br /> f � pectian by Date <br /> Additional Comments; 1 <br /> ❑ Still 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M 1L`» a t,� <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, "S't_k., CA 95201 (iY <br /> FEE G <br /> INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY <br /> DATE PERMIT'NO. <br /> It <br /> t EH 13-24(REV.1/951 �oC.� C/' /�•�4 f <br /> EH 1428 J <br /> / 1 7-'.3 <br />