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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> AP� PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> - 1, (Completer 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. This application 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 <br /> Local Health District. 4 <br /> // �7 1 3q <br /> Job Address (b 7 I P�v� f' "` � City Lot Size + ��� PM <br /> Owner's Name r r 1 r� �i Address 933,2-0 <br /> -7 <br /> Phone <br /> I <br /> Contractor ' " Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> OTHEI( �U <br /> PUMP-INSTALLATION ❑ SYSTEM REPAIR ❑ R ❑ �( <br /> DISTANCE TO NEAREST: SEPTIC TANK X <br /> �* 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 ❑ Manteca Dia. of Well Excavation . Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> " ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i l <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ;Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 y <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sev6er is <br /> available within 200 feet.► <br /> Installation will serve: Residence_ Commercial_ Other <br /> w y" <br /> Number of living units: Number of bedrooms i <br /> Character of soil to-6 depth of 3 feet: Water table depth IN <br /> SEPTIC,TANK ` ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ "o Method of Disposal v <br /> Distance to nearest: Well Foundation Property Line 1 <br /> LEACHING LINE." ❑ <No. & Length'of lines a Total length/size <br /> FILTER BED '- `NO' rO -.Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ "Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL 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, andil <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's 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 person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature , <br /> certifies 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- <br /> tion laws of California." + <br /> The applicant must call for all required " pections. Complete drawing on reverse side. " <br /> Signed X Titl e: <br /> Date: r <br /> FOR PARTMENT USE ONLY <br /> Application Accepted by [/L/ Date Area <br /> I Pit or Grout Inspection by Date Final Inspection b Date <br /> J <br /> Additional Comments <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 " ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Balt Permlt/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ' � I <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT ND. <br /> INFO <br /> + EH 1324 4REV.)i P 5) Q , <br /> EH 14-28 �� �S R l / VAD _�k—/X- <br />