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APPLICATION FOR PERMIT <br /> •rte:... <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CAS <br /> Telephone (209) 466 6787 �G <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU (0��C� <br /> l <br /> (Complete in Triplicate) <br /> p I s <br /> 6r� de t�gd. Tfiis"application is <br /> 6 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w J1r lau ns of t1i"e San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wail/pump and the Rule g � f <br /> Local Health District. <br /> r <br /> '73 ri <br /> ^� - City Lot Size PM <br /> Jab Address s <br /> Ly IAA— Address Phone Y <br /> Owner's Name �- <br /> _ " '._ _ License No. Phone <br /> f Contractor Address <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT L-1 <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ = SYSTEM REPAIR OTHER ❑ <br /> � .-- —D1Sf'OSA'L-F1 D" T"PROPTL_IN - <br /> TA CE TSN A- EST�SEPTIC-TANK-- ' 5I WER-LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE '`.,r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ns <br /> ❑ Gravel Pack El Tracy yp Type of Grout <br /> r ' h] Other ❑ Delta Depth of Grout Seal <br /> hi Public - <br /> ' I Igigation Approx. Depth l I Eastern Surface Seal Installed by <br /> r ��^��� H p / State Work Done ` <br /> Repair Work Done ❑ Type of Pump_ H. V� <br /> Well Destruction" ❑ lY VVell'Diamete (� Sealing Materia! (top 501 <br /> ial IBelow 50'1 <br /> Depth Filler Mater <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t ] DESTRUCTION I I alvailablelw_i within 200 feet.) if public sJir , <br /> s <br /> Installation will serve: Residence L Commercial— Other <br /> Number of living units: Number of bedrooms <br /> t Water table depth <br /> Character of soil to a•depth of 3 feet: <br /> Capacity No. Compartments <br /> SEPTIC TANK ElType! �f9 _ - -- i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Property Lin <br /> •'Distanim to"n�st"'�WeH """�'�""rFoundatiori e <br /> r <br /> I LEACHING LINE ❑ No. & Length of lines Total length/size t <br /> I Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation p Y <br /> a r <br /> SEEPAGE PITS I I ,Depth Size i Number i <br /> o. =�- -r.�.+F- -�-- " -tion Pro ert Line <br /> SUMPS ❑ Distance to nearest: Well - FoundaP Y <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the_work will bed'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•tt a performance of the work for which this permit is issued, I shall not <br /> employ any person' such manner as to-become subject to-workman's compensation laws of California." Contractor's hiring of sub-contracting signature <br /> certifies the follow' : "1 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of ia•" <br /> The applica call for all req it d inspe t ns. Complete drawing on r ver a idK¢J <br /> Signed X Title: <br /> ' 4;7 <br /> RTME USE ONLY <br /> Date Area <br /> i Application Accepted by - . - x , <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Dat <br /> Additional Comments: � <br /> El Stk 466-6781 171 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 CK RECEIVED BY DATE PERMIT NO. T—f <br /> INFO97' <br /> E AMOUNT REM ED CASH f I nn <br /> EH13-24IFrEV.1/Xsl <br /> EH 14-20 <br />