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APPLICATION FOR PERMIT <br /> SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 1604 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in'Triplicate) <br /> /or install the work <br /> n describ .This <br /> Application is hereby made the i nCoun ul Ordinalnce No.649 for sewage or permit <br /> No. 1862 for wellapump and the Rules and(Regulations of he Sancation is <br /> Joaquin <br /> made in compliance with Sann the County <br /> k Local Health District. <br /> s }. Vtlt City �Yr Lot Size PM <br /> Job Address ;1 / r <br /> Address 7`r o 6 N. 4 uJ 1 F . Phone i <br /> Owner's Name 1 <br /> _ Phone 1 <br /> Contractor's Name ®t�l� j License No. DESTRUCTION ❑ <br /> a WELL REPLACEMENT ❑ J <br /> TYPE OF WELL/PUMP: .� NEW WELL ❑ SYSTEM REPAIR ❑ OTHER <br /> PUMP INSTALLATION ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Depth of Grout Seal Type of Grout <br /> ❑ Public [:1 Other 171 Delta p <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> State Work Done <br /> Repair Work Done El Type of Pump <br /> H P. <br /> Sealing Material (top 50'1 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 50'} <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Elavailable wio septic th nepermitted if public sewer is 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> 4 Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK El :Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> �No. & Length of lines Total length/size ` —s <br /> LEACHING LINE Prs ert Line <br /> FILTER BED 71 Distance to nearest: Well Foundation p y <br /> k Depth Size Number <br /> I SEEPAGE PITS Property Line <br /> M SUMPS EJ Distance to nearest: Well Foundation P rtY <br /> I 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 of California."Contractor's hiring or subcontracting signature <br /> certifies the following:"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 /> I tion laws of California." <br /> The applicant must call for all required ins t. ns. Complete drawing on reverse side. p�J <br /> j Signed <br /> .('f,/) Title: Date: d T <br /> R DEPART N�-SJSE ONLY !� ��? <br /> (% Date v `9 Area <br /> ion Accepted by <br /> Applicat p ^� <br /> 3�- �? F�,,allnpaltion by Date 221,2p— <br /> Pit <br /> Pit or Grout Inspection by Date <br /> Additional Comments; <br /> `r ❑ Stk 466-6781 El 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 /> *y <br /> FEE CK# RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> 00 <br /> i. + EH 13-24(REV.10!83) <br /> EH 14'-26 - - _---- <br />