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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />` 1601 E. HAZEL T ON AVE., STOCKTON, CAP CO P y <br /> Telephone 1269) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> , . (Complete in Triplicate) wo1 0 <br /> Local Health District for a permit to construct and/or install the work herein described.This application is <br /> Application is Iteieby made to the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 far sewage or No. 1862 for welllpump end the d Regulations of the San Joaquin <br /> ✓ow <br /> Local Health District. , ,ss- (t[ C 77E-.at�� <br /> w <br /> Cityra �_ Lot Size PM <br /> Job Address R <br /> 2 I. Address Phone <br /> Owner's Name i. 1 !? , 4k' <br /> Contractor <br /> y�etry! ; Address Yi�ef G� _ License No.gq?U s--Phone 771 <br /> I <br /> TYPE OF WELL/PUMP: /V NEW WELL ❑ �, WELL REPLACEMENT ❑ DESTRUCTION ❑ h <br /> SYSTEM REPAIR 11OTHER ❑ <br /> + P MP INSTALLATION ❑ _ I <br /> ? SEWER LINES — -DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK �� �/�m = <br /> FOUNDATION, }� AGRICULTURE WELL-tY1 &- OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE_ OF tNELL P"S88CE <br /> AREA CONSTRUCTION ECIFICATIONS <br /> J ei ❑ Open Bottom ❑ Man- feta �Cf°� Dia. of L11eli-Ekeetiatitm -sLrn"+ r `r�1dh^ Dia. of Well teasing ti <br /> Industrial S cilications <br /> T of Gasin ,... <br /> D Domestic/Private ❑Gravel Pack Tracy <br /> Type g � o af�tu 7T of Groul[L�+ <br /> 1 rout Seal <br /> '1 Public <br /> �" n Other Ll Delta Depth of G <br /> M I - � <br /> ,* _.Approx,f]apth I I Eastern Surface Seal Installed by <br /> I I Irrigation _ <br /> Repair Work Done L3 Type of Pump H.P. State Work Done <br /> Sealing Material{top 50'1 <br /> Well Destruction D Well OrFilter <br /> g + <br /> Filler Material (Below 50'1 <br /> Depth <br /> i TYPE OF SEPTIC er <br /> WORK: NEW INSTALLATION 11 REPAIRIADDiTION I I DESTRUCTION I ! aly�ilablerwithin 20�feet.) if public sewer is �.-. <br /> Installation tl serve: Residence ` .Commercial Other_�.-- <br /> Number of bedrooms <br /> Number of fivin its: Water table depth <br /> Character ol'Soil to a th of 3 feet. No. Compartments <br /> SEPTIC TANK ❑ Mfg Capacity <br /> Method of Disposal <br /> PKG.TREATMENT PLT.❑ I <br /> iDistance to nearest: Well Foundation Property Line <br /> I I <br /> i Total fengthJsize <br /> LEACHING LINE Ci No. & Length of lines <br /> j ❑ Distance to pearesti`- Well o tion Property Line <br /> IE <br /> FILTER BED " I <br /> I SEEPAGE PITS I I Depth <br /> Size er <br /> SUMPS 0 Distance to nearest: Well + Foundation Prop <br /> 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 Dibtrict. <br /> Home owner or licensed agent's signature cenifies the following: "1 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 Califomia."Contractors hiring of sub contracting signature <br /> h ! certifies the fallowing:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's campensa• <br /> tion taws of California." <br /> The applicant r^st c It for It a uired•insp ctions. Complete drawing on reverse side.� 1 f <br /> Title: lff&f+ Date: <br /> i Signed <br /> R DEPARTMENT USE ONLY <br /> Date a ea <br /> I Application Accepted by 2� <br /> d <br /> ' Pit or Grout Inspection byDate Final Inspection by <br /> Additional Comments: <br /> © Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 D Tracy 835.6385 <br /> Applicant- Return all copies to: Environmental Health Permil/Gervlces 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I FE£ AMOUNT DUE AML)UNT REMITTED <br /> — <br /> CASH <br /> DATE PERMIT•NO. <br /> + EH 132 IREY.tiwil �S. �7 Y�' <br />