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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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 hetehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descrihed. This application is <br /> made in compliance with San Joaquin county Ordinance No.549 for sewa(ie or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I <br /> t _ City �/ Lot Size— <br /> Job Address ( <br /> Phone <br /> Owner's Name . <br /> Address _ <br /> Address —L4.� ice nse Na _.. Phone <br /> Cortracto • <br /> TYPE OF WELL/PUMP: NEW WELL rJ WELL REPLACEMENT G DESTRUCTION Li <br /> PUMP INSTALLATION SYSTEM REPAIR 0 OTHER U <br /> SEWER LINES DISPOSAL FLD -- PROP. LINE .. <br /> DISTANCE TO NEAREST: SEPTIC TANK PITSlSUMPS <br /> FOUNDATION AGRICULTURE WELL OTHER-WELL_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> (l Oen Bottom © Manteca Dia. of Well Excavation Dia. of Well Casing O <br /> *ndustrial p <br /> ' Type of Casin, Specifications (, <br /> Domestic/Private ❑ Gravel Pack U Tracy q— `s Type of Grout "V <br /> I Public 71 Other n Delta Depth of Grout Seal -. _ yp <br /> I I Irrigation Apprcx. DepthQi I EasternSurface Seal Installed by_. <br /> Repair Work Done Ll Type of Pump,"' H.P. HJ�� State Work Done •_ _ <br /> Well Destruction ] Well Diameter _ Scaling Material Itop 501 <br /> Depth_._ <br /> Filler Material Melow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I DESTRUCTION I : (No septic system permitted if public sewer is <br /> available within 200 teet.) <br /> Installation will serve: Residence —_ Commercial_ Other <br /> Number of living units: Number of bedrooms_- <br /> v I I <br /> Character of soil to a depth of 3 feet: Water table deet <br /> SEPTIC TANK ❑ .Type,Mfg` 'Capacity. _ No. C <br /> f _ Mathd ispoSal <br /> PKG. TREATMENT PLT:U- <br /> -� Distance to-nearest —Foundation Property Lina <br /> 1 I1 <br /> LEACHING LINE � No. & Length of lines — Total length/size <br /> 1_1 <br /> FILTER BED n Distance to nearest: Well _ Foundation — Property LineENMONMEMAL HEALTH <br /> ru <br /> - _Size ---. — Number <br /> SEEPAGE PITS I Depth -. <br /> SUMPS Ll Distance to nearest: Well— Foundation_. _ Property Line _ <br /> k <br /> DISPOSAL PONDS G I <br /> application and that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> I hereby certify that I have prepared this <br /> rules and regulations of the San Joaquin Local Health District. not <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit issued, I shall ure <br /> employ any person in such manner as to become subject to workman's compensation laws of California.'"Contractor's hiring or suacontracting 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 applica�Qustjail �required�spactions. Complete drawing on reverse side- <br /> —89 <br /> Signed _ Title: <br /> Date:GSL—� <br /> FOR D ARTMENT USE ONLY <br /> Data Area <br /> Application Accepted by � <br /> Pit or Grout Inspection by <br /> Data_ _ Final Inspection by L- Date <br /> i , <br /> J — <br /> I Additional Comments. <br /> J Stk 466-6781 D Lodi 369-3621 L1 Manteca 823-7104 F Tracy 835-6385 <br /> Applicant - Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> CK CEIVD BY <br /> INFO DATE <br /> FEE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH REE <br /> EH 13.24 IREb <br /> k EH 1.-26 <br /> E _ <br />