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q°1!� Ay h <br /> x <br /> APPLICATION FOR PERMITlye <br /> � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> A3 1601 E. HLCZEILTOVAV•E., STOCKTON, CA J'bN (I i <br /> Telephone (209) 466-6781 V <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. Thisiaplication is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin 4E <br /> Local Health District. <br /> li <br /> I <br /> Job Address City Size PM <br /> of <br /> t <br /> q C� <br /> Address ��/' !� Phone '� <br /> Owner's Name A �► <br /> Contractor ss Q ' cense No. Phone <br /> TYPE OF WELL/PUMP: NEW AELL ❑ WELL REPLACEMENT ❑ DESTRUCTION f r' <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _.,_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> © Industrial "� ❑ Open Bottom D Manteca Dia. of Well Excavation <Pia. of Well Casing <br /> r <br /> EJ Domestic/Private °-2 ~D-Gravel.P.ack.—. �-d Trac ----- T Ye of_CasiSpecifications <br /> M Public -Cl Other n Delta Depth of Grout Seal Type of Grout <br /> I Irrigation _.-Approx. Depth I I EasternSurface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump `. 1 lFt.'}. vt irk[ State-Work-Done"_'"""` <br /> Well Destruction Well Diameter J Sealing Material Itop <br /> 3 [ li '•� <br /> Depth Filler Material (Below 561 'x- �"'�� f' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION l I DESTRUCTION l I IN septic'sy'st m permitted if public sewer is I <br /> available-within 2004eeta-- --�6 „ <br /> Installation will serve: Restdenee_ Commercial— Other } <br /> Number of living units: -,`/ Number of bedrooms 1 <br /> f jAt. <br /> Character of�rto as d� Water table depth <br /> 3-feet: - ' - <br /> SEPTIC TANK ❑ Type/Mfg Capacity t��� ''t.No. Compo tments1.\*r !L f I <br /> PKG. TREATMENT PLT. ❑ i �f\�3 Method of Disposal �t ' Q <br /> Distance to nearest: Well Foundation F - '�Pfoperty Line x <br /> I LEACHING LINE Cl No. & Length of lines Total length/size' ,. � a t• r '""� <br /> I Pr`o ert Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation p y JJ. <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ <br /> I <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 regulationsoLlh <br /> an Joaquin Local Health District. <br /> Home owner or li sed agen signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pe on in such man r as to became subject to arkman's compensation taws of California.”Contractor's hiring or sub-contracting signature <br /> certifies the Ilowing: ..certify a •n the pe o nee th wo k for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws o Gaiifornia.` <br /> i <br /> The appli ant mus ca f squire p ate rowing on rev <br /> Signed X Title: bate: C,Jf' <br /> 1 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date "� � Area 1 <br /> t; <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 /> plicant- Return all copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ;! <br /> l E <br /> Ft{ FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> a EH 13.24[REV.1/)15) <br /> •� 2 II <br /> y €H 14-2e -- <br />