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3;,OD <br /> { APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ; <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete.in Triplicate) <br /> Application is hereby made to the San 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 Ordinance No.549 for sewage or No. 1861 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District...,, ± �*,�' <br /> Job Address l city �w- Lot Size PM <br /> r <br /> ��60L/ Address <br /> Owner's Name Phone <br /> Contractor <br /> TYPE�OF WELL/PUMP: NEW WELL <br /> WELL REPLACEMENT C1 DESTRUCTION EJ q I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKISSl_L_ SEWER LINES DISPOSAL FLD'�ROP. LINE <br /> ` I FOUNDATION W AGRICULTURE WELL —. OTHER WELL PITS/SUMPS , <br /> qq,� _ INTENDED USE _ TYPE OF WELL PROBLEM AREA.1 CONSTRUCTION SPECIFICAT NS At <br /> -t� ID• Industrial a❑ Open-Bott6m' ❑ Manteca Dia. &Well Excavation Dia. of Well Casing <br /> � � "---- �--� � '4 1:53� ` "' pl/[_ dC fe �fr� Specifications ! <br /> ffDomesticlPnvate A+'Ldravel Pack `-❑Tracy -.-Type of CasingT <br /> ❑ Public L1 Other El Delta Depth of Grout Seal /—�1:1 Type of Grou <br /> p ` <br /> ` �kQO-Approx. Depth A'£astern Surface Seal Installed by <br /> El Irrigation � I <br /> Repair Work Done LJType of Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'! <br /> Depth Filler Material (Below 50'.), <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION El DESTRUCTION ❑ (No septic system permitted if public sewer is ' <br /> d .l -- - available within 200 feet.) i <br /> Installation wi Residence_ Commercial a <br /> J } <br /> E <br /> Number of living units: tuber of bedrooms !other <br /> Character of soil to a depth of 3 feet: <br /> x 4 Water table depth ' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments f �" <br /> PKG- TREATMENT PLT. ❑ <br /> i ? Method of Disposal t <br /> Property Line 1 <br /> Distance to nearest: Well Z Fou on <br /> LEACHING LINE LlNo. & Length of lines Toth/size- <br /> FILTER BED ❑ Distance to nearest: Well +Foundation Prope, ine <br /> -R = <br /> SEEPAGE PITS ❑ Depth - Size � ,umber""'""'-""""'-` <br /> SUMPS Ll Distance to nearest: Well Foundation t.• �..F Property Line <br /> y. <br /> DISPOSAL PONDS ❑ <br /> 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. i ' <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 following: "I certify that in the performance of the work for,which this permit is issued,I shall employ persons subject to workman's corn pe nsa- <br /> tion laws of California." I t <br /> The app:7� <br /> n ctions. Complete drawing,on r*ELY <br /> id <br /> `. <br /> Signed y itl Date: a <br /> OR DEP RTMENI <br /> 4 Date �r �^ Area <br /> Application-Accepted-by <br /> Date Final Inspection by Date <br /> Pit or Grout Ins�ction by <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi A& 1 ❑ Manteca -7104 gTracy 835.6385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO _*7 ��.��/y (��� J <br /> + EH 3-24 EV.5/a57 ,/ 9—IL) t� / 97 3"1 <br /> EH 1426 <br />