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APPLICATION FOR PERMIT NNW <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,�- (0 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED oh <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 <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquir <br /> Local Health District. pQ <br /> City Lot Size PM <br /> Job Address <br /> J <br /> Owner's Name 1�F Add ess — — Phone <br /> Contractor's Name "4/114-ense No. Phone <br /> r3/D�f <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT"❑ DESTRUCTION ❑ <br /> ` PUMP INSTALLATION EJ 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 /> C3Industrial CJ-Open Bottom ❑ Manteca - Dia. of Well-Excavation Dia. of Well Casing <br /> ❑ DomesticZPrivate El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ElOther ❑ Delta Depth of Grout Seal Type of Grout CA <br /> Cl lrriga n —APprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work DOT 0-. :Type of Pump H.P. <br /> State Work Done S <br /> Sealing Material (to 501 _ O <br /> Well Destruction ❑ Well Diameter 9 p <br /> Depth- Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR;ADDITION ❑ DESTRUCTION ❑ (No septic sy nem feet.)ed if public sewer is_ <br /> .� Installation will serve: Residence_ Comrnercial Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a d;th,of 34teeZ: <br /> Water table depth (� <br /> r SEPTIC TANK{ Type/Mfg <br /> _�_ Capacity No. Compartments <br /> Method of Disposal <br /> PKG.TREATMENT PLT.❑ <br /> Distance to nearest: Well Foundation__ Property Line <br /> � 1 <br /> LEACHING-1ANE 16 No. & Length of IinjYs <br /> Total length/size <br /> FILTER BEO1 ❑ Distance to nearest: Well Foundation -Property Line <br /> T 1 <br /> SEEPAGE PITS ❑ Depth Size. Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify thaf•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. <br /> licensed agent's signature certifres.the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licet to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> employ any person rased a manner n"I certify that s tthe performance of t <br /> in o become subjeche work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies the following: <br /> tion laws of California." <br /> The appMv,­����� <br /> rawing on r rse side. <br /> Ttle: r— F� ^� Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY n� _ <br /> Date Area C J� <br /> Application Accepted by �1 L5 <br /> Date G Final InsL <br /> Date <br /> Pit or Grout Inspection by <br /> Ad nal Comments: <br /> Stk 466-6781 ElLodi 369-3621 ❑ Manteca 823 7104 ❑ racy Stk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, <br /> FEECK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> EH 1324(REV.10/93) �jZs/g j p <br /> EH 14-26 0 1 <br />