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f APPLICATION FOR PERMIT , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR 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. 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 A�V, �� iy <br /> City Lot Size PM � it <br /> Owner's Name _ Address <br /> Phone <br /> Contractor 1110t <br /> dress /✓t'r�� License No,j Phf17 jy� 1 <br /> TYPE OF WELL/PUMP: NEW WELL � one_ <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ E <br /> DISTANCE TO NEAREST:,SEPTIC TANK SEWER LiNES <br /> DISPOSAL FLD. 1 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELLd <br /> PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 9 Open Bottom ❑ Manteca Dia. of Well Excavation �7�r <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing -- `` <br /> f l Public Type of Casing Specifications ` �V <br /> n Other" ❑ Delta Depth of Grout Seal ip z _ t\ <br /> I I Irrigation �prA 'Type--of Grout— `1 t <br /> pprax. Depth l- I Eastern 5 rface Seal Installed by - <br /> Repair Work Done EJ Type of Pump 7 alp H p <br /> Weil Destruction ❑ Well DiameterState Work Done I <br /> Sealing Material atop 50'1 <br /> Depth <br /> -Filler-Material (Below-50').- <br /> TYPE OF SEPTIC WORK: MEW INSTALLATION !1 REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence„ Commercial available within 200 feet.) <br />�. Other�__ <br /> Number of living units: NurNer of bedrooms <br /> Character of soil to a depth of 3 feet: V <br />' ,-,�_,SEPTIC TANK ❑ T e/Mf -- M1 Water table depth <br /> Type/Mfg g Capacity,r No, Compartments <br /> PKG.TREATMENT PLT. C1 ¢q.� . <br /> `_ ' d �� Method of Disposal <br /> Distance to neo st: Well Foundation" _. <br /> Property Line <br /> v 1,. 4 � <br /> LEACHING LINE <br /> ❑ No. & Length of Ii s �° <br /> FiLTER BED Total length/sae <br /> ❑ Distance to nearest: Well -Foundation .r <br /> I Property Line <br /> SEEPAGE PITS I'I Depth Size <br /> Number <br /> SUMPS ❑ Distance to nearest: Well >j <br /> DISPOSAL PONDS El Property- Property Line <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 <br /> rules and regulations of the San Joaquin-Local-Heaith.District. laws; and_ _ _ __ <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 /> a <br /> .i-,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 a plicant m t call for all q d inspections. Complete drawing on reverse side. <br /> Signed c j <br /> Title: i <br /> Date: <br /> FOR EPA TM NT USE ONLY <br /> Application Accepted by i <br /> Data Area <br /> Pit or rou nspection by — DateL <br /> Final Inspection <br /> � <br /> Additional Comments: T` <br /> ❑ Stk 466-6781 U 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 95241 <br /> FEE <br /> INFO AMCK <br /> OUNT DUE AMOUNT REMITTED <br /> - CASH RECEIVED BY GATE PERMIT'NO. <br /> +.EH 13-24IREV.iin5� '. <br /> EH 14-26 <br />