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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT � �* <br /> 1601 E. HAZETON AVE., STOCKTON, CA h/7/V�_ <br /> Telephone (209) 466-6781 WA, �, L <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (��-70 <br /> " (Complete in Triplicate) '* <br /> Application is hereby made to the San Joaquin Local Health District for a permit t1 on for and/or install the work pump and the Rules and in described of is Sanapplication <br /> Joaquin <br /> Coun <br /> r made m compliance with San JoaquintY Ordinance No.549 for sewage o <br /> Local Health District. 4. <br /> O�� Lj/�a�f f City/ Lot Size PM <br /> Job Address <br /> Owner's Name ailLic <br /> /t <br /> �`rA�dress / Phone <br /> Contractor 's 4 4?-D Address' <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ip SYSTEM REPAIR ❑ OTHER ❑ <br /> i DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> .i <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF"WELL i PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia" of Well Casing <br /> ❑ Industrial ❑ Open Bottom , ❑ Manteca Dia" of Well Excavation f <br /> ❑ DomesticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public <br /> Cl Other ,` F1 Delta Depth of Grout Seal Type of Grout =- -1-1 <br /> I i Irrigation _.Approxi Depth I I Eastern Surface Seal Installed by <br /> " H.P. <br /> State Work Done <br /> Repair Work Done ❑ Typ,of Pump <br /> f Well Destruction ❑ Well Diameter Sealing Material flop 50'1 <br /> Depth ' I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORKy NEW INSTALLATION l l REPAIR/ADDITION t iDESTRUCTION (No septic <br /> ilable systhin m rented ifpublicsewer is <br /> � r .. <br /> Installation will serve: Residence''_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> r W�er table depth <br /> I Character;of soil to a depth of 3 feet: <br /> SEPTIC'TANK ❑ Type_ <br /> /Mfg Capacity No. Compartments <br /> PKG.-TF EATMENT+P T ❑,. T Meth68 of Disposal <br /> r <br /> Distance to nearest: Well Foundation I Property Line <br /> LEACHING LINE ` 17-1 No. & L'ength•of lines Total length/size <br /> FILTER BED L1 Distance to nearest: Well Foundation �"" Property Line <br /> i <br /> Number tip <br /> SEEPAGE PITS I I depth- _ Size <br /> SUMPS Cl Distance to nearest: Well Foundation d Property Line <br /> f <br /> DISPOSAL PONDS' ❑ }' <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 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 oflCaiifiirnia." Contractor's hiring or sub contracting signature <br /> Certifies the following: "l 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 call for-all-requited-'ins"pections:'Complete drawing on_reverse side. <br /> F Or Title: •s .r� Date:.I'®�/U RIF, <br /> I Signed X "_ <br /> DEPARTMEf1iT USt ONLY <br /> Application Accepted by_ Date `e �,�/^ �� Area <br /> Pit or Grout Inspection by <br /> Date --/- <br /> Final Inspection by e. V Y Date <br /> Additional Comments: <br /> ?�7 f <br /> ❑ Stk 466-6781 ❑ Lodi 36913621 Cl Manteca 823-7104 ❑ Tracy 835-6385 <br /> Appl"cant - Return all copigs to: Envi onmenta Health Permit/ er.ice�ss 1601 E. t:azelton�Ave., P O. Box 2 15 <br /> 01 <br /> � w o �Lt �^o�LO t�ti f3 W t c Y L�-. mac �t e IT �C_s <br /> FEE MOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITCK T-7 'ND. (J <br /> INFO `/` <br /> r + EH 3-24(REV.r/r;s1 5 ,Q �!, `"✓ - , <br /> EH 14-2e <br />