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i - s <br /> APPLICATION-FOR PERMIT I <br /> SAN JOAQUINiLOCAL HEALTH DISTRICT <br /> Ili 3 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> s Telephone (205) 466.6781 <br /> .. . . , . , <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED . {' <br /> .,�. rs�.wf Comple#e in Triplicate) - <br /> .• .• -: <br /> l Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This a li <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ruias and Regulations of the San Joaquin <br /> Local Health District ,� pp cation is <br /> Job Address191 Or <br /> � ` <br /> /9/JIL PM <br /> Owner's Name <br /> ddress �J <br /> Phone =+� <br /> Contractor's Name �� a < <br /> TYPE OF WELL/PUMP: License No. <br /> NEW WELL Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION loll— SYSTEM REPAIR ❑ 9 <br /> DISTANCE TO NEAREST: SEPTIC TANK' OTHER ❑ ` <br /> SEWER LINES — DISPOSAL FLD. PROP. LINE 1--4 <br /> FOUNDATION. AGRICULTURE WELL <br /> INTENDED USE OTHER WEa_L,—� PITS/SUMPS � <br /> .TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATION <br /> ❑ Indu ria! t – <br /> f�°llpe^ from ❑ Manteca Dia. of Well Excavation <br /> -mastic/Private Dia. of Well Casing <br /> Ci Public ravel Pack ❑ Tracy Type of Casing ,. <br /> ❑ Other '71 Delta Depth of Grout Seal � � Specifications <br /> ❑ Irrigation ---Approx. Depth ❑ astern YPe of Grout <br /> Repair Work Done ❑ Type of Pump I Surface Seal Installed by <br /> Well Destruction ❑ Well Diameter H P State Work Done <br /> Sealing Material (top 50') <br /> Depth Filler-Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic <br /> - P system permitted ii puAis <br /> Installation will serve: Residence available within 200 feet.) <br /> �Comme►cial, Other <br /> Number of Irving units: Number,of bedrooms - <br /> Character of soil to a depth of 3 feet: k1 <br /> SEPTIC TANK ❑ Type/Mfg Water table depthI.�PKG.TREATMENT PLT. ❑ Capacity [�o_ Compartments <br /> Method of DisposalDistance to nearest: Well FoundationProperty LineLEACHING LINENo. & Length of lines FILTER BED Total length/size❑ Distance to nearest: Well - Foundation Propert}iLine . <br /> SEEPAGE PITS ❑ Depth <br /> Size Number <br /> SUMPS' ❑ '.Distance to nearest: Well - <br /> DISPOSAL PONDS ❑ Foundation Property Line-- <br /> I <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. <br /> Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus call for all required inspe cio complete drawing on reverse side. <br /> Signed <br /> J---�, Title: c� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r P `2 , ' /';, <br /> # Date Area U <br /> Pia or rout nspecti <br /> Date Final Inspection by <br /> Additional Comments: �,/ Are Date o 0 <br /> ❑ Stk 466-6781 .T. ❑'Lodi 369-3611 ❑ Manteca- <br /> 823-710.4 11 Tracy 836385 <br /> Applicant- Return all copies to:'Environmental-Health Permit/Services 1601',E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br /> FEE AMOUNTDUE <br /> INFO' - ; !AMOUNT REMITTED R RECEIVED BY DATE r <br /> PERMIT"N0. 1 <br /> F <br /> EH 1324(REV. 10!93) <br /> EH 1428 <br />