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APPLICATION FOR PERMIT Lt 'I,L <br /> I� <br /> • SAN JOAQUIN LOCAL HEALTH DISTRICT D <br /> ► 1601 E`-HJAZELTON� E; STOCKTON, CA <br /> p - <br /> Tele hone (2091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ,AUL 9 1988 <br /> (Complete in Triplicate) fNV1R <br /> oM RV-11"'T'+ <br /> Application is heieby made to the San Joaquin Local Health District for a permit to construct and/or install the wor� aation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules �f.�San Joaquin <br /> Local Health District. <br /> Job Address Ci[ �`--�'`Lit Size PM I <br /> qs <br /> Owrier;s-Name ddressJA QC Phone <br /> 'Cnntfactor �� fess in X "� License No.IL 2- -?2,—Phone Ca m <br /> TYPE:OF WEL'L'/-PUMP" NEW OELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR .❑ OTHER ❑ , <br /> DISTANCE TO=NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP,...-CINE <br /> ;+ FOUNDATION AGRICULTURE WELL OTHER WELL PITSk_ tJMPS <br /> INTENDED.USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i- <br /> _,,Z-Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of.:WY ll Casing <br /> a,Dornestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specific ons <br /> FPdblic Cl Other 1-1Delta Depth of Grout Seal pe of,Grout _ <br /> 11 r' 'A <br /> I•'I'Irrigation Appfox, Dept l I Eastern Surfa a eal Installed by - <br /> Repair Work Done 2---Ty—P,of Pump u HIP. State Work Done YCa� <br /> ty <br /> i Well Destruction Q Well Diameter Sealing Material Itop 50'I <br /> Depth Filler Material IBelow 50'}Iw <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION i I (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> insiallation will serve: Residence— Commercial— Other y�+ <br /> Number of livingunits: Numher of bedrooms # <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK . ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number l <br /> SUMPS, L Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ' <br /> 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 /> rules and regulations of the San Joaquin Local Health 1311trict. I. <br /> Home own sed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not P <br /> employ y person in ch mann as to co a subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifi the f0Nowing:rllifr <br /> ertif. t a i t pe ormanc of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion Its of Cali mi <br /> The plica m c ui Complete drawing o re erse side i <br /> 1 <br /> Signed Title: Date: <br /> FOR-DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by Date Area <br /> C��i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621. ❑ Manteca 823-7104 . ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Seryices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> INFO CASH I f ) l p <br /> r.EH 13-24 1REV-1/H 51 <br /> EH 14-26 <br />