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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICR j <br /> 1601 E. HAZELTON AVE., STOCKTON, CA y �t cvw ��99 <br /> Telephone (209) 466-6751 d <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU €, 17 1 $ <br /> (Complete in Triplicate) <br /> t;nn��, 'Z 'N1[-'TAL IIEAL TIA <br /> Application is hereby made to the San Joaquin Local.Health District for a permit to construct and/or install tfiYe'3t § dfir`efi.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. }1362 for well/pump and theR as entl Regulation of the San Joaquin <br /> as <br /> Local Health District, <br /> / �a.�--- <br /> Job Address Ll/ / ,/ �"- .�/ City _ Lai Size PM <br /> Owner's Name��- Address tw4A <br /> /� `f,� Phone t� <br /> Contractor Address t>r,t�6 B,cf� . gJ p!-License NoAQ W2- Phon£J�j,- <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE_ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> *dustrei ❑Open Bottom D Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 5eDomesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 11 Public ❑ Other El Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ­Approx. Depth ( I Eastern Surface Seal Installed by <br /> Repair Work Done W Type of PumpH.P. �Q. State Work Done <br /> r4 <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 581) <br /> Detuh Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIRFADD1710N f I DESTRUCTION 11 (No septic system permitted if public sewer is <br /> Installation will serve; Residence_ Commercial_ Other available within 200 feet.) <br /> Number of living units:__ Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.❑ - <br /> DistMethod of Disposal <br /> ance to nearest: Well Foundation property,Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to ttearast: Well Foundation. Property Line <br /> SEEPAGE PITS I I pepth Size <br /> SUMPS Number <br /> ❑ Distance vo nearest: Weil Foundation <br /> y Line Propert <br /> DISPOSAL PONDS ❑ - <br /> i fiareby cortiry[hat 3 have prepared this application and that the work will be done in accordance with San county Joa uin <br /> rules and regulations of the San Joaquin Local Health District. 4 My ordinances,state laws, and <br /> Homo owner or licensed agents signature certifies the}glowing: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> ernpby any parson in such manner as to hacome subject to workman's compensatbn laws of California."Contractors hiring or subcontracting signature <br /> certifies the following:"I certify thst'in rho parfortnance pf the work for which this permit is issued,k sha31 <br /> tion laws of California." <br /> The applicant must call for all required inspections.Complete drawion employ persons subjecYto workman's compensa- <br /> Title: r= <br /> ng arse side. <br /> Signed X <br /> <-- Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �Sa_�-�e=J <br /> Date U a Area <br /> Pit or Grout Inspection by U Data <br /> Final Inspection by Date II-3-bar <br /> �- Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-.3621 ❑ Manteca 823-7106 ❑ Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health PermR/Services 1 <br /> 601 E. Hazelton Ave., F.O. BOX 2009, Stk., CA 901 <br /> INFO AMOUNT DUE AMOUNT REMITTED ON <br /> TT- Ij -ALL <br />