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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) application is <br /> ordinance No.549 for sewage or No. 1862 for welllpump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San JoaquinLocal Health District for a permit to construct and/or install the work herein described.This <br /> PP <br /> made in compliance with San Joaquin County O <br /> Local Health District. PM <br /> City of Size <br /> Job Address CKa— I <br /> Phone <br /> Address <br /> Owner's Name Phone <br /> " r License No. <br /> Address DESTRUCTION ❑ <br /> Contractor WELL Np, EMFN ❑ <br /> EW WELL ❑ OTHER ❑ <br /> TYPE OF WELL/PUMP' SYSTEM REPAIR <br /> PUMP INSTALLATION d DISPOSAL FLD• PROP_ LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES� T.�, �. -�+ Z-yQ�TS/SUMPS <br /> ••''"" ' AGRICULTURE WELL OTHER WELL <br /> I - FOUNDATION <br /> fINTENDED'USE TYPE OF WELL PROBL, E�MAREA CONSTRUCTION SPECIFICATIONS Dia. of Well_Casing <br /> ❑ Manteca Dia-.of�Wel1-Excavation- , <br /> S Q'Open Bottom ,Specifications <br /> "`C] Industrial i p Tracy? Type of Casing <br /> Domestic/Private ❑ Gravel Pack Type of Grout <br /> ("1 Public l 1 Other <br /> F1 Delta,�' Depth of Grout Seal 4 r <br /> t Surface 5eal.lnstalled by <br /> E I Irrigation —_APProx. Depth I 1 Eastern rn State Work 1131, <br /> l of Pump H.P. <br /> Repair Work Done ❑ Type " <br /> Sealing Material 401354i * .'` �` � <br /> ' <br /> well Destruction, ❑ Well Diameter k' r ' <br /> Depth �=?�--•� iFiller Mater11 ial [B11 elow 50'F <br /> l er itled,if,:pu�lic'sewer is <br /> TYPE QF SEPTIC WOflK: NEW INSTALLATION I:l REPAIR/ADD17iON f 1 DESTRUCTION i I (No <br /> lablell7oitrriFil2�ft= �I <br /> I 1 <br /> serve: Residence_ CommercialY l Other��� PJROn�r1 MEN J N <br /> installation will L T�' <br /> k Number of living units: Number of bedrooms Water tralSle�e r �� <br /> l Character of soil-to-a depth of 3 feet: a Capacity— No. Compartments <br /> ' SEPTIC TANK ❑ TypelMtg Method of Disposal <br /> _ w PKC. TREATMENT.PLT.-❑ "�- I <br /> Distance to nearest:; Well <br /> Foundation Property Line <br /> Total length/size f <br /> LEACHING LINE ❑ No. & Length of lines Property Line <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation <br /> l '=, Size Number <br /> SEEPAGE PITS [ I Depth Property Line ,Y <br /> Foundation <br /> SUMPS O' Distance to nearest: .._ <br /> well <br /> 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 /> rules and regulations of the San Joaquin Local Health District.g' certify <br /> that in the sl <br /> Home owner or licensed agmen er as torbecome subjecrlto wlorkman'scompensation Iw soof California." Contractor'slhiri gt or sub-contracting s permit is issued, lsignlaturoe <br /> employ any perso In uch <br /> r certifies the folio in . "l certify that in the performance of the work far which this permit is issued, I shall employ persons subject to workman's compensa <br /> f tion laws of is-" <br /> The applic t call for all req i ed inspe i ns. Complete drawing on r v rse side. <br /> Date: <br /> Signed X Title: <br /> r FOR DEPARTMENT USE ONLY <br /> Date / Area <br /> Application Accepted by <br /> t ! Date Final Inspection by <br /> Pit or Grout Inspection by <br /> Additional Comments: 835-6385 <br /> Stk, 4&§,6781 _L di_369-3621 ❑ Manteca,.823-7104._-. A O Tracy, <br /> �.. ❑ i7 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2049. Stk., GA 95241 „R <br /> CK - RECEIVED BY DATE f ERMIT NO. <br /> FEET.---AMOUNT-DUE—�•�--AMOUNT REMITTED CASH <br /> —INFO <br /> ♦ EH 13-24(REV.I i n 51 � <br /> EH 14-26 1 <br />