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APPLICATION FOR PERMIT <br /> ! � i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 F <br /> 1 II <br /> PERMIT EXPIRES) YEAR 'FROM.DATE ISSUED <br /> {Complete in Triplicate) ;; s_ _. F �@,. ,•. <br /> Application is he,eby made to the San Joaquin Local Health District for a permit to construct an 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. 41 "'"' <br /> 0 / :fes 4 '�� , r �/ <br /> Job Address ;l ` CityS3 4 Lot Sized G PM <br /> I <br /> ,Owner's Name II Address Y � .Phone <br /> Contractor I ess - License No.�+ Phone <br /> - _ ... . . — <br /> TYPE OF WELL/PUMP: III NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUM SYSTEM REPAIR ❑ OTHER ❑ 3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE POSAL FLD. PROP.: LINE <br /> FOUNDATION -� AGRICULTURE WELL OTHER WELL S/SUMPS _ <br /> INTENDE jiTYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS M r <br /> ❑ Industrial om ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i ❑ Domestic/Private <br /> E, Gravel Pack Type of Casing Specifications <br /> ❑ Public '❑ Other ❑ 'Delta Y <br /> hof Grout Seal Type of Grout <br /> Yp W <br /> ❑ Irrigation Approx. Depth " ❑ Eastern Surface Sea <br /> Repair Work Done ❑ Type of Pump ° H.P. State for !�pp <br /> Well Destruction ❑ Well Diameter ~r Seating Material (top 50'1 I! O\ <br /> Depth, l Filler. elow 501 �� 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONPAIR/ADDITION DESTRUCTION 0,1No septic system permitted if public sewer is <br /> a I— - available within 200 feet.) !' <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units. Number of bedrooms-3 Y <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ �, Type/Mfg Capacity .No. Compartments) <br /> PKG. TREATMENT PLT. ❑' Method of Disposal <br /> ¢ a Distance to nearest;. _ i'Well * Foundation Property Line IL ' <br /> LEACHING LINE 1p T No. & Length of lines If 0 A 0,AA <br /> Total length/size <br /> FILTER BED" _EJ Distance,to nearest: , Well: foundation' Property Line I <br /> -. iI <br /> SEEPA& PITS " ❑ !'Depth ` Z Size Number i <br /> 4 l <br /> SUMPS ❑ Distance to nearest:" Well Foundation + sProperty Line <br /> DISPOSAL PONDS ❑11� <br /> 1 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. i <br /> Home owner or licansed�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 sut-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 we' Drkman's compensa- <br /> tion laws of California." <br /> I The applicanA must call lfw all requir d inspections. Complete drawing on reverse side. I <br /> t 8 Signed X 50 Title: .'^, Date: <br /> z FOR DEPARTMENT USE ONLY }� 19 <br /> Application Accepted by % Date <br /> l. " <br /> ,I. <br /> D <br /> r Grout Inspection by Date � Final Inspection by I y <br /> Additional"Comments: { l _NlI <br /> ❑ Stk 466-6781 ❑ Lodi 3693621 ❑%Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all coples':to: Enviro{lmental Health Permit/Services 1801 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE-1" AMOUNT REMITTED- CASH RECEIVED"BY DATE PERMIT N0. <br /> + EH 13-24 1REV.7 H 5) <br /> .. EM 14.28,: - - <br />