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- APPLICATION I"IFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH;DISTRICT <br /> 1601 E. HAZE T ON AVE.;;STOCKTON, CA t. <br /> 'Telephone (209) '466-6781 9 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> ;Y.-- r •�, (Complete_ in Triplicate)- r =,e { <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. <br /> Job Address 7 �IjQ" i� <br /> City ! R Lot Size PM <br /> Owner's Name ---- <br /> Address <br /> ./r Phone <br /> Contractor l3���/t Address <br /> TYPE OF WELL/PUMP: License Na. Phone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ . SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER El <br /> LINES' DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> TI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Ll ElGravel Pack Dia. of Weil Casing <br /> ❑ Tracy - Type of Casing <br /> ❑ Public ❑ OtherSpecifications <br /> ❑ Delta Depth of Grout Seal <br /> ❑irrigationType of Grout <br /> ---Approx. Depth C1 Eastern Surface Seal Installed by • <br /> Repair Work Done ❑ Type of Pump H p <br /> Well Destruction ❑ Well Diameter State Work Done <br /> Sealing Material Itop 50'! \\ <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW 1NSTALLATiON ❑ REPAIR/ADDITION ❑ DESTRUCTION fNo septic system permitted if public sewer is <br /> w available within 200 feet.! <br /> Installation will serve: Residence, Commercial� Other �'`� �_' i <br /> Number of living units:_ ,Number.of bedrooms��_-�Y`' f <br /> Character Of'soil to a-depth of 3 feet: A❑ Type/Mfg— <br /> SEPTIC TANK Water table depth <br /> PKGr,`' � - <br /> Capacity l No. Compartments <br /> . TREATMENT PLT. ❑ �.,,.__ 9 <br /> s i I Method of Disposal <br /> Distance to nearest: Well Foundation # <br /> {i Property Line <br /> LEACHING LINE' ❑ No. & Length of lines <br /> FILTER BEDTota! length/size <br /> ❑ Distance to nearest: Well Foundation <br /> � Property Line <br /> SEEPAGE PITS IDDepth Size <br /> SUMPSNumber <br /> ❑ Distance to nearest:- Well Foundation <br /> DISPOSAL PONDS Li Foundation Line <br /> I hereby certify that i have prepared this application and that the work_will be,donein accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District, ,. , .;, <br /> Home owner 11 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 /> tion laws of California. <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, shall employ persons subject to workman's compensa- <br /> " <br /> The applicant must call for all required inspections. Complete drawing on re arse side. <br /> Signed ' ' <br /> Title: ° Date: I d 7 <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by Q�] <br /> Date �O / Area <br /> I <br /> Pit or Grout inspection by Date _ � � <br /> Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7704 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE DUE AMOUNT REMITTED CK <br /> INFO AMOUNT RECEIVED BY': PATE' PERMIT NO. <br />+ EH 13-24 IREV.1/n 5)- jy I !r�`/"i(_"�"/j ,�-�/ , <br /> EH 14-26 �� ' <br />