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c <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA r <br /> Telephone (209) 466-6781 �l <br /> PERMIT EXPIRESx1 YEAR FROM DATE ISSUED '0 7r.: <br /> r.: (Complete irr Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District fora ..,. <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage No. 1882 for well and/or <br /> pump and the Rules and Regulations of he San li Joaquin <br /> Local Health District. , <br /> Job Address <br /> LA <br /> city <br /> i _ - Lot Size _ PM ' <br /> Owner's Name ` -S -`Address <br /> j � lfe:r� Phone <br /> Contractor's Name _ Na. e <br /> TYPE OF WELL/PUMP: NEW-WELL License❑ Phone <br /> WELL REPLACEMENT C01DESTRUC'T ION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK __ OTHER ❑, <br /> - ;, SEWER LINES ­­�­ DISPOSAL FLD. PROP. LINE, <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM REA_ i; ..- PITS/SUMPS <br /> CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca 4i Dia. of Wel! Excavation_ �` <br /> 11Domestic/Private ❑ Gravel Pa'ckl `TM Dia. of Well.Casing <br /> { :❑ Tracy fiype`of Casing Y <br /> ❑ Public ❑ Other ❑ Delta ' `, Specifications \ <br /> v' Depth of Graeit Seal Type of Grout - <br /> ❑ Irrigation _p,pprox. Depth 0 Eastern <br /> Surface Seal Installed by- <br /> Repair Work Done ❑ Type of Pump f H. ' '-� State Work Done -�_ <br /> Well Destruction ❑ Well Diameter'I � I Sealing Material (top SOtia.�..— <br /> Depth - I Filler Material f8elow 60') <br /> TYPE OF SEPTIC WORK: NEW INSTALILATION ❑ REPAIR/ADDITION DESTRUL.710N ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence ' available within 200 feet.) <br /> Commercial! Other ' <br /> Number of livingunits: �'t <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet: , Y <br /> SEPTIC TANK Ll Type/Mfg Water table depths <`f <br /> PKG. TREATMENT PLT. ❑ Capacity_ No. CompartmentMethod of Disposal C' <br /> Distance to nearest: Well Foundation ll <br /> Property Line <br /> LEACHING LINE X No. & Length of lines <br /> FILTER BEDTotal length/size ' C -: <br /> ❑ Distance to nearest: Well—�i�&Foundation <br /> Property, Line <br /> f <br /> SEEPAGE PITS A pepth <br /> Size r� Number tZAK <br /> SUMPS ❑ Distance to nearest: Well B+ <br /> DISPOSAL PONDS <br /> Foundation . Property Line` <br /> ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaqu n,county ordinances, state laws and r <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 of California."Contractors hiring or sub contracting signature <br /> certifies the fallowing:"I 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 California." , <br /> The applicant must call for all required inspections plate drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> 'Application Accepted by <br /> DB=E - �- <br /> Area <br /> Pit or Grout Inspection by Data <br /> —=.'Final Inspection by ' fib{�j"��� - <br /> TDate <br /> Additional Comments: E . . <br /> ElStk 678 <br /> 466 1 ❑ Lodi (� <br /> 368-3621 ❑ Manteca &23-7104 ❑ Tracy 83-6385 U <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 <br /> FEE AMOUNT DUEEJAMC01)UNTMITTED CK <br /> ` INFOCASH RECEIVED BY DATE PERMIT"N0. <br /> a <br /> 13-24 IREY.10/831 0 i <br /> 01 <br />