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f y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES""'YEAR FROM DATE ISSUED' <br /> (Complete.in Triplicate) w <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 - City Lot Size .PM <br /> I�{ Owner's Nam - Address if 9q " Phone S <br /> F20 . , , /j� <br /> M Contracto lll�Q�� G C !.� Address Q License No( Phone <br /> t TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> a FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r ❑ 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 <br /> i ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> I 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 �0 <br /> ' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPAI ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is X' <br /> t F ?w* (J available-within 200 feet.) <br /> !! Installation will serve: Re )dente ✓ Commercial_ Other `. <br /> k _ t <br /> Number of living units: Number of room <br /> Character of soil to a dept f 3 feet: -- ' t Water table depth t <br /> j.: t <br /> F -SEPTIC TANK Type/Mfg Capacity . No. Compartments <br /> f PKG. TREATMENT PLT. ❑ / ;r � y / Method of Di) osal <br /> Distance to nearest: Well�— Foun_dafion�Q Property Line <br /> n <br /> LEACHING LINE 9?-"No. & Length of lines ""' ® �# ' � "Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation's Property Line <br /> 'SEEPAGE PITS Depth �� Size Number <br /> C" ', <br /> -SUMPS �;.❑ .Distance,..to.nearest:,.,...-Weil."/ —�Foundatiori__.- (�..__..-- .Property Line <br /> s 'DISPOSAL PONDS ❑ <br /> 'h-hereby certify that I have preparedrthis 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-Joaquii-LocirHealth District--- 4 <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 ,-i <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 /> certifie's 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-applicent must call f all quired inspections. Completed drawing on reverse/��1de._,, t /!1 //{►� pIAL �7(y <br /> F , I �r ''.[kI' # �'wr J l/� 5 � Py..�-�f A i} U <br /> S ed 3 Title: r Date, <br /> I 4 <br /> + j FOR DEPARTMENT USE ONLY <br /> ( Application Accepted by- / • fl� _ Date Area -. <br /> or Grout Inspection by Date Final Inspection by7t Date L <br /> Additional Comments: <br /> j ❑ Stk 466-6781 ❑ Lodi 363621 ❑ Manteca 823-7104 [] Tracy 835-6385 ,q <br /> t k Applicant- Return all copies to: Erivironmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE' AMOUNT DUE AMOUNT REMITTED - CASH RECEIVED BY DATE l'ERMY `NO. <br /> INFO _ �. <br /> +EH 13-24(REV., /a 5) <br /> t EH 1426 <br />