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lE <br /> APPLICATION FOR PERMIT <br /> . 'SAN JOAQUIN TON AVL LOCAL,HEALTH DISTRICT <br /> 1601 E�WAZE' ,,STOCKTON, CA <br /> }:.(�8 IEF Telephon <br /> � e 209),46fi-6781 <br /> -PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> F1J%J ROMVN_VAL (Complete in Triplicate) <br /> M1�/ ER1�ICES <br /> un Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hei ade to the San <br /> 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 <br /> Local Health District. <br /> 4 �ize <br /> City PM <br /> Job Address � ( .�Q <br /> ��� L Address Phone <br /> Owner's Name <br /> L <br /> ddress f-b <br /> lo,Z License No. � �� � Phone <br /> ". ctor DESTRUCTION ❑ <br /> NE"_CE WELL ❑ WELL REPLACEMENT ❑ <br /> TYPE Or-WELLIPUMP: OTHER ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR <br /> i S DISPOSAL FLD. PROP. LINE <br /> SEWER LINES --- PITS/SUMPS <br /> DISTANCE TO NEAREST: SEPTIC TANK AGRICULTURE WELL OTHER WELL <br /> FOUNDATION <br /> 11VTEIDED USE TYPE OF WELL PROS A CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ lndusirial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> r; ❑ Tracy Type of Casing <br /> ❑ Domestic/Private✓_,._-W Gravel Pack Type of Grout <br /> ` C3� Other Cl Delta Depth of Grout Seal n <br /> 1, (`l Public' _{' Surface S at Installed by <br /> I 1 Irrigation Yrr Approx. Rept I.i Eastern H.P. State Work Done <br /> II Repair Work Done�+C Type of Pump Sealing Material (top 50'1 <br /> ¢ Well Wei ,r[� Well Diameter Filler Material ISelow 501 <br /> Depth <br /> T PEtOF SEPTIC 1h/ORK NEW I INSTALLATION 17 REPAIRIADDITION l I DESTRUCTION I I availablelwit in 200 ie tithed i(public sewer is <br /> 'Ahsstallation✓will serve: Residence— Commercial__ Other I <br /> ✓'Number of living units: Number of bedrooms } Water table depth <br /> `. <br /> ( Character of^sod to a depth of 3 feet: No. Compartments <br /> � �i ,,f capacity- <br /> 1441C TANK-T- - ❑"'TYpe#Mfg' 4 Method of Dispose! <br /> 1 PKG.TREATMEN7 PLT:d-^"'-' i Property.Line <br /> i -- Dista[nce�tk nearest: Well Foundation - <br /> � . t ° k•-f l <br /> LEACHING LINE - ^'❑" No.: Length of lines b <br /> Total length/size <br /> Foundation< Property Line <br /> FILTER BEDto nearest: Well , <br /> ! Number <br /> SEEPAGEIFV7S I I Depth Size <br /> S ,,,.,r Foundation( Property Line <br /> r _ SUMPS e ;-f-# . El Distance to nearest: Well <br /> au�'r.� <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, an <br /> rules and regulations of the San Joaquin aquin Local Health District. <br /> ermit is issued, <br /> sh <br /> }: i__- . <br /> t --.__Home ow ne person n such a atnne gas torhe om— WRfies th act Ilo wlorkman'eR ompensation I wsooi California." Contract which shngi op sub-cont actings signlatu�e <br /> amp oy p <br /> certifies a following:"Ice i y that in a ante f the or or which is permit is issued, I shall employ persons subject to workman's compensa <br /> tion la' sof Calif rnia." <br /> The,ap )scant t f all requi d plate d awing n rev ide .� <br /> Title: - Date: r <br /> Signed <br /> R EPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Data <br /> Final Inspection by � Date <br /> Additional Comments: <br /> ❑ Stk 466.6781 E3 Lodi 369-3621 C7 Manteca 823-7104 ❑ Tracy 835-6385 <br /> t€: <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> { CK RECEIVED BY DATE PERMIT�NO. <br /> k. FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO � X343 <br /> 53-24 1REV.I/n 51 � . <br />