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3 <br /> APPLICATION FOR PERMIT <br /> C,7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE,—_I ON AVE., STOCKTON, CA <br /> Teleph6_ne (209).466-67817 <br /> PERMIT EXPIRES tYEAR'FROM DATE ISSUED' <br /> .. ,'. <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 se;7,age or No 1862 for well/pump and the Rule.s and Regulations of the San Joaquin <br /> -Local Health District. 0 <br /> PM <br /> City <br /> i­' _+Lot Size <br /> Job Address <br /> -Owner's Name, 'Address PhoneD <br /> -C-_ Address License N/��Phone <br /> ontractor NEW WELL L1 WELL REPLACEMENT U DESTRUCTION El <br /> TYPE OF WELL/PUMP: PUMP INSTALLATION\.F7,` SYSTEM REPAIR OTHER El <br /> DISTANCE TO NEAREST: SEPTIC TANK ------- PR SEWER LINES _ DISPOSAL FLD.— OP. LINE <br /> I <br /> FOUNDATION _ AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> .4 <br /> tNTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAZIONS <br /> 0 Industrial <br /> D Open Bottom 0 Manteca Dia. of Well Excavation I Dia, of Well Casing rw6omelticl Private 11 Gravel Pack D Tracy Type of Casing Specifications <br /> Ll Public El Other C1 Delta .-Depth of Grout Seal Type of Grout <br /> 0 Irrigation ---Approx. De D E rf ce Seal Installed by <br /> �asternH.P. urface Se 0 <br /> I I �� State 'Work Done <br /> Repair Work Done Li Type of Pump <br /> Well De ruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material !Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D REPAIR/ADDITION L DESTRUCTION 0 INo septic system permitted it putAIG Sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial— Other <br /> ed ,f if sewer is <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Characker of soil to a depth of 3 feet: <br /> No. Compartments <br /> SEPTIC TANK 0 Type/Mfg Capacity <br /> -of-Disposal-- <br /> PKG. _-+--Meth.d <br /> Distance to nearest: Wel Ida <br /> Founda Tion Property Line <br /> Lergth of lines <br /> LEACHING LINE 0 [No�,&'' ' - 1`1 Total leqgth/size <br /> ' I r L Property Line <br /> FILTEKBED�, F] istanqqto nearest: -Well__ Foundation <br /> SEEPAGE PITSA0 Depth - —Size Number <br /> ,, ) - <br /> SUMPS 'El Distance to nearest: Wel i I Foundation-- Property Line <br /> PONDS: J 11 � <br /> . A--. leI I <br /> DISPOSAL POND <br /> hereby�certify that...I 6ve prepared this application and th <br /> he i:th6work will be done in accordance w0h San Joaquin county ordinances, state laws, and <br /> rules and'regulations of the San Joaquin Local Health District.t4 I/' <br /> Home owner or licensed agent's signature certifies the f ollo�dir�d: "I certify that in the performance o thework for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to w7'orkman's compensation laws of Califo:rn a. Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of <br /> 1h ,II <br /> 6 work for which this permit is issued, I sI ernploy persons subject to workman's compensa- <br /> tion laws of CaMornia." <br /> The applies11 f 11 d inspections. Complete drawing on reverse side. <br /> Signed Date: <br /> FOR DEPARTMENT'USE-ONLY <br /> i Date Area <br /> Application Accepted by <br /> V, Final Inspection by Date <br /> Pit or Grout Inspection by <br /> - At <br /> Additional Comments: IV I <br /> El Stk 466-Ml 0 Lodi 369-3621 0 Manteca 823-7104--): El Tracy 835-6385 <br /> ust or a quire <br /> Area <br /> Date <br /> Applicant- Return all copies to; Enviio'inmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box MIX),"Stk., CA 95201 <br /> CK# 7 ZPERMITV NO. <br /> FEE 7 AMOUNT DUE AMOUNT REMITTED. CASH RECEIVED BY DATE <br /> INFO — . !. <br /> f5" g:�0 .. ; .: V F-(.' % <br /> + E14 3.24(REV.1/8 5) ' . :?, <br /> EH 11,26 <br />