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APPLICATION FOR PERMIT <br /> { SAN JOAO.UIN LOCAL HEALTH DISTRICT <br /> 3 1601 E. HAZELTON AVE., STOCKTON, CA--�EPAYMENT,�E� <br /> Telephone (209)'466-6781. <br /> PERMIT EXPIRES 1 YEAR FROM`DATE 1SSU5 201988 <br /> (Complete in Triplicate) <br /> described.This application is <br /> Application is hereby made to the San.�oaquin Local Health District for a permit to construct and p apfm � of�San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No.1862 for well/ a RVrCs <br /> Local Health District, <br /> City Lot Size PM <br /> Job Address <br /> f Pho <br /> Owner's Name 4 <br /> Address License No. Vol Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WE WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ � <br /> DISTANCE.TO NEAREST::SEPTIC TANK - <br /> SEWER LINES.-` DlSP05AL_FLD. PROP,. LINE, <br /> Y FOUNDATION AGRICULTURE WELL V OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom 17 Manteca Dia.-of-Well Excavation <br /> YTracy lade Specifications <br /> �LDomestic/Private Q Gravel Pack — <br /> Q Other ❑ Delta } *Type of CasingDepth of Grout Seal Type of Grout <br /> ❑ Public UQ <br /> ❑ Irrigation --Approx. Dept ❑ stern _ Surf ace,Seal,lnstalled by { <br /> State Work Done <br /> Repair Work Done ❑ Type of Pump , ti <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth <br /> Filler Material (Below'501 <br /> TYPE OF SEPTIC WORK: "NEW INSTALLATION ElREPAIR/ADDITION 11 DESTRUCTION El (No s septic <br /> tsystem <br /> tem eitlted if public sewer is <br /> Installation will serve: Residence— Commercial Other 1 <br /> Number of living units: Number of bedrooms , iv, 1+r <br /> c Water table depth y <br /> Character of soil to a depth of 3 feet: <br /> ❑ T e/Mf Capacity No. Compartments <br /> SEPTIC TANK YP g Method of Disposal <br /> E PKG, TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line, <br /> " .. <br /> LEACHING LINE El No. <br /> length/size No. & Length of lines Ll <br /> Line <br /> ! FILTER BED Distance to nearest: Well Foundation Property ` <br /> i, 4� <br /> Size Number <br /> 17 <br /> SEEPAGE PITS Depth L <br /> " ' ine <br /> L "= SUMPS ❑ Distance to nearest: Well— Foundation Property <br /> i; <br /> DISPOSAL PONDS El <br /> 1 hereby certify that l have prepared this application and that the work will bce with San Joaquin county ordinances, state laws, and <br /> e done in accordan <br /> rules and regulations of the San Joaquin Local Health District. <br /> k 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 /> such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in s <br /> certifies the following: 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. Complete drawing on reverse side." r <br /> Title: Date: <br /> Signed <br /> D ENT USE ONLY 2 <br /> Date v Ar a r. <br /> Application Accepted by _ <br /> n by Date <br /> Pit or Grout Inspection by <br /> Date Final Inspectio <br /> I. <br /> Additional.Comments: <br /> [' ❑ Stk 466-6781 Q Lodi 369.3621 ❑ Manteca 823-7104 10 Tracy $35-6385 . <br /> rmitlServices 1601 E."Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Pe <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> AMOUNT DUE AMOUNT REM! ED ^^H <br /> +EH 1&24{REV.1/e s1 f s� <br /> EH 14-26 <br />