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s ✓ I . APPLICATION-•FOR PERMIT PAYMI ENT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT RECEIVED <br /> t 1601 E. HAZEL T ON AVE., STOCKTON, CA2� DEC 12 199010 <br /> F Telephone (209) 46&-G2 Yf �.. <br /> :PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIRONMENTAL HEALTH <br /> (Complete in Triplicate) PERMl1 f SERViES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. +s application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> [ Cit Lot Size PM <br /> Job Address � + <br /> r? Phone 02r <br /> Owner's Name Address <br /> I 1,,,�I <br /> Contractor ! <br /> Address License No.9Z, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION LJ <br /> 1.PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 07WER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. r PROP. LINE. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL .,� PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I i <br /> ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of WeN Casing <br /> «❑ Industrial _ Specifications <br /> I <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing p t <br /> Ll Other n -Delta Depth of Grout Seal Type of Grout <br /> i'l Public i,�,; .r^r ' <br /> ! I Irrigation Approx. Depth i I Eastern Surface Seal Installed by F <br /> Repair Work Done AL <br /> per= <br /> H p State Work Done <br /> Type of Pum <br /> Well Destruction L1 Depth <br /> Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material IBelow 501 ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION`1:1 DESTRUCTION t I (No septic. <br /> syst 200 emitted if public sewer is , <br /> 0.- 0 <br /> Installationwillserve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth, <br /> Character of soil to a depth of 3 feet:Ir - <br /> SEPTIC TANK ❑ Type/Mfg Capacity_------L No. Compartments <br /> PKG. TREATMENT PLT. ❑ , Method of Disposal's l- <br /> Distance to nearest: Wel! Foundation Property Line t <br /> LEACHING LINE ❑ No. & Le}gth of lines Total length/size <br /> FILTER BED LJ Distance,to nearest: ;`Well Foundation Property Line <br /> 1. t Number <br /> SEEPAGE PITS 11 Depth Size ' �> <br /> t,< , — L-I-�-Distance-to nearest: Well Foundation Property Line— �y <br /> ++ I <br /> .rSUMPSr..�.�.-- _ <br /> DISPOSAL PONDS ❑ :T <br /> I hereby certify that I have prepared tlils 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 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 taws of California." Contractorrs hiring or sub-contracting 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 /> tion laws of California." 4 <br /> The applicant st c II f all required inspections. Complete drawing on re erse side. <br /> Date: <br /> Signad X - Title: <br /> FOR DEPARTMENT USE ONLY <br /> R Date �� a <br /> Application Accepted by oe�4 <br /> /_✓/�-�, <br /> Pit or Grout inspection by <br /> t Date Final Inspection Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Envilronmental Health Permit/Services 1601 E..Hazelton Ave., P.O. Box 2009, 51k., CA 95201 <br /> FEE CTF!!! ;DATE PERMIT,NO. <br /> INFO AMOUNT DUE AMODUNNT REMITTED C <br /> 00- <br /> + EH 13-241REV.1/ns� 7.,jL'�v� l ..l � <br /> EH t4-26 <br />