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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT y <br /> 1601 E. HAZE:.I ON AVE., STOCKTON, CA . <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 /> ty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin Counj <br /> Local Health District. , <br /> �'} L9 , City Lot Size PM <br /> Job Address 6 `` i - <br /> 9 <br /> —3�� <br /> t � Phone <br /> Owner's Name •Address <br /> .� icense No. Phone <br /> Contractor's Name 1 <br /> TYPE OF WELL/PUMP:.. NEW WEL WELL REPLACEMENT DESTRUCTION <br /> t 't'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> + DISTANCE TO NEAREST:'SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> 'FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 7 <br /> I INTENDED USE TYPE OF WELL, PROBLEM AREA CONSTRUCTION SPECIFICATIONS 10 <br /> i ❑ Industrial ❑ Open Bottom" L] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing °� b0 Specifications <br /> L3 Domestic/Private ❑ Gravel Pack Tracy T e of Grout <br /> ❑ Public ❑ Othei Ll Delta Depth of Grout Seal YP <br /> ❑ Irrigation -L--Approx. Depth ❑ Eastern Surface Seal Installed by 9 <br /> i Repair Work Done ❑ Type of Pumpi <br /> H.P. State ork Done <br />' Well Destruction Well Diameter] Sealing Material (top 50'1 _ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION El (No <br /> lseptiwihsystem permittedlic sewer is ITa �� ... 11++Installation will serve: Residence_ Commercial fOtherF <br /> Number of living units: Number of bf Brooms Water table depth lrR <br /> Character of soil to a depth of,3 feet: No, Compartment <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ b �� <br /> Distance to nearest: Well, Foundation Property Line <br /> LEACHING LINE ❑ No.& Length ofIlines Total length/size <br /> FILTER BED ElDistance to nearest: Well Foundation Property tine <br /> SEEPAGE PITS ❑ Depth Size <br /> Number. i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> k 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 /> I rules and regulations of the San Joaquin Local Health District. <br /> 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 /> Home owner ar <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's 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." <br /> The applicant m �call. al uir spections. Complete drawing on reverse side. , <br /> Signed <br /> Title: —a XO-f 49Date: <br /> FOR DEPARTMENT USE ONLY �7 <br /> ®� N Date/'Z 6^�</ Area <br /> Application Accepted by p r <br /> { ' pate <br /> Pit or Grout InspectioFinal Inspection by_ Date <br /> f n by ` <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 n Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy'Tracy-835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE '` „ RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED 7CAWEH 1324{REV.101831 � <br /> cu�d� _ � �• Oil O`er - <br />