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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA PA Y M ENT <br /> Telephone (209) 466-6781 R E C E r V>:D <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) AUG 7 <br /> Application is hateby made to the San Joaqn Local Health District for agpermit to construct and/or Inst"Kugrk rein described. This application is <br /> made in compliance with San Joaquin CountyOrdinance No.549 for sewage or No. 1662 for well/ ump an t 1 i tW?of the San Joaquin <br /> Local Health District. PERM-TT/SERVICES <br /> ALTH <br /> Job Address City Lot Size PM <br /> Owner's Name Address L� 8� ALI6 Phone <br /> Contractor I prJa�C�° "�`� -_Address License No1?_Wa_0 Phon I <br /> TYPE OF WELL/PUMP: NEW WEL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ y, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD.: " PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS,,- <br /> ❑ Industrial 71Open Bottom ElManteca Dia. of Well Excavation 'Diat`of Wel( Casing <br /> ADomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public (7 Other ❑ Delta Depth of Grout Seal rJ Type of Grout <br /> I E Irrigation i —.-Approx. Depth ' l I Eastern �urface Seal Installed by <br /> Repair Work Done Did Type of Pump �c_Y1 H.P. _ State'Work Done <br /> Well Destruction "❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ('I REPAIR/ADDITION 11-' DESTRUCTION I I INo'septic system permitted if public sewer is �"\\ <br /> 'C' 4 available within 200 feet.) v <br /> 1 Installation will serve: Residence_ Commercial_ Other t ` � <br /> Number of living units: Number of bedrooms <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. ❑ r r }1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property line <br /> DISPOSAL PONDS ❑ r - 4` `F <br /> t I hereby certify that I have prepared this application and that the_-work,will be done in acco�daneerwitK San Joaquin county ordinances, state laws, and <br /> 4 rules and regulations of the San Joaquin Local Health District. t l , <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 became subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature T <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 /> k <br /> The applica ust call for all ire spections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> tApplication Accepted by Date / Area <br /> ff <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> t <br /> F Additional Comments: j <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 AMOUNT DUE AMOUNT REMITTED K RECEIVED BY ,DATE PERMITNO. <br /> C <br /> INFO -STI` <br /> + EH 4IREV.I/H5) <br /> EH 14--2 <br />