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a� n� <br /> - APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT MI <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Q <br /> Y, Telephone (209) 466-6781 Lt <br /> t <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED -Mo - <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. This application is <br /> { made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1B62 for well/pump and the Rules and Regulations of the San Joaquin <br /> j Local Health District.�" [ ,�/ <br /> }j Job Address +� �? C LAi ft <br /> �— City ��+'Lot Size PM <br /> Owner's Name f` 'Address 3nZ� .`-- -z 1�D r j r_\VL P-f+one <br /> I Contractor S Address License No. Phone <br /> TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC"TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTH L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON STRU SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Weli Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> f'1 Public Ll Other Delta Depth of Grout Seal Type of Grout V) <br /> I I Irrigation _..A epth ! I Eastern Surface Seal Installed by <br /> Repair Work Done El pe of Pump H.P. State Work Done <br /> Well Destruc ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L) REPAIR/ADDITION i I DESTRUCTIO I (No septic system permitted if public sewer is �J <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK C1 Type/Mfg a Capacity '"" ' No. Compartments <br /> PKG. TREATMENT PLT. Qx Method of Disposal f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number rR <br /> 1 { <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line [)[J <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, and <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 Calif ni ' <br /> T a licant all fo II re 'ad Wections. Com to drawing on reverse side. <br /> Signed Title: Date: U / <br /> r, <br /> JOR DEPARTMENT USE ONLY <br /> I Application Accepted by Date r+ Area 00 <br /> Pit or Grout Inspection 4y Date Final Inspection by Date 9 � <br /> ,..�.�� <br /> Additional Comments: �`'-"^c� ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 © Manteca 823-7104 Tracy'.835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK t RECEIVED BY DATE PERM17'NO. <br /> ` y <br /> + EH 1329(REV.+/H 51 �C <br />