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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 3 <br /> .j <br /> 1601 E. HAZETON AVE., STOCKTON, CAx $ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> he work <br /> cation is <br /> lor <br /> all t <br /> Application is hereby made to the Joaquin County <br /> Ordinance No. 549 for sewage or Health District for,a permit <br /> No. 1862 for cwell/dpump and the Rules and'R Regulations of trhe Sanis s Joaquin <br /> made in compliance with San y <br /> Local Health District 4 <br /> �,. s � � �� V• -- City "1 Lot Size PM , <br /> Job Address _ ' <br /> ~ I Phone <br /> Address <br /> Owner's Name <br /> Contractor Address ' <br /> icense No. d Phone? <br /> TYPE OF WELL/PUMP: NEW WELL ❑ `r' WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER I-]PUMP INSTALLATION ❑ , . <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> ;SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATIONAGRICULTURE WELL t OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia of Well Casing <br /> © Industrial Ll Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Type of,Casing <br /> t Specifications <br /> C1Gravel Pack O�Tracy <br /> ❑ Domestic Private Type of Grout — <br /> [1 Public 17 Other I. Cl delta Depth of Grout Seal <br /> e <br /> Depth I I Eastern Surface Seal Installed by <br /> 11 Irrigation —..Approx. P 3 . - State Work Done <br /> Repair Work Done L7 Type of Pump H.P. <br /> G Well Destruction LIWelk.Diameter Sealing Material Itop 501 <br />! Filler Material (Below 50'! <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION r6l,- E�AIR/ADDITION i I DESTRUCTION I I availablewithin200 feetc system r,) ~ted if public sewer is <br /> bi <br /> V Co <br /> k Installation will serve: Residence� _mmercial Other t <br /> Number of living units: Number of bedrooms <br /> _.411 .:. Water table depth <br /> Character of soil to a depth of 3 feet: t <br /> SEPTIC TANK CIType/Mfg 6�Cr CapacityNo. Compartments <br /> - Method of Disposal <br /> PKG. TREATMENT PLT.❑ ' <br /> Distance to Weare : } Well Foundation —-Property Line <br /> ' 6 Total length/size 10 <br /> LEACHING LINE OL—No. & Length of lines <br /> ❑ 'Distance to nearest: —Weli —""'-""Foundation Property Line <br /> FILTER HED r <br /> r / <br /> SEEPAGE PITS l 11 Depth ` Sixe_ <br /> _� 10 Number <br /> SUMPS f3istance to nearest: a Well <br /> Foundation M Property Line <br /> &rty <br /> DISPOSAL PONDS ❑ t <br /> I hereby certify that I have prepared this application and that the work willl be done in accordance with San Joa uin county ordinances, state laws, and <br /> 115 rules and regulations of the San Joaquin Local eal h Mltrict. ■ <br /> rtify the following: "I cethat in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies <br /> employ any person in such manner as to become subject to workman's comperisation laws of California." Contractor's hiring or sub-contracting signature <br /> c fres 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 k <br /> tion of California." i [ <br /> The applican us call r I re lred i 'pecti s Co etc drawing an rev rse side. J� r /} <br /> Title: Date. b a V fA <br /> L <br /> Signe <br /> FOR PARTMENT USE ONLY -0 <br /> Date <br /> Area _ <br /> i Application Accepted by _ R- 27 <br /> Date <br /> R Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: e <br /> - wr• <br /> ❑ Ma .9 <br /> r. LJ Stk 4ti6 6781 fl Lodi 369-3621 Manteca 823-7104 Tracy 835 5 y�. (S p <br /> l Health Permit/services 1601 EHaxelton Ave , P.O. B x 009, St'k.}C,A 95201 <br /> Applicant - Return all copies to: Environmental <br /> FEE MOUNT 156E AMOUNT REMITTED CKs RECEIVED BY DATE PERMIT'NO. <br /> INF CASH <br /> } +.EN13.24(REV.r/x5) D ,o� <br /> EH 1l-2B <br />