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�>'?F. <br /> PLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> w PERMIT EXPIRES 1 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 /> e P <br /> Jab Address Q City Size <br /> Owner's Nameilsi�lifl�.Q� /jZi/i1/l <br /> s/ Qa r Phone - 4 <br /> I vI <br /> Contractor's Name Licen No. Phone �C ' <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION F-1 PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ,.FOUNDATION ___ZSrAGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE F WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 12 Industrial pen Bottom ❑ Manteca Dia. of Well Excavation ^ <br /> Z, �- <br /> El Public 1:1 Dia. of Well Casing <br /> ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t <br /> ❑ Public ❑ Other ❑ Delta <br /> ❑ Irrigation Depth ofGro.ut Seal <br /> Tye f Grout <br /> ---Approx..Depth ❑ Eastern Surface <br /> Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> �_,m—well Destruction ❑ Well Diameter <br /> Depth De Sealing Material Itop.50'} <br /> ° <br /> t p " Filler-Material [Below 50') <br /> j_�TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION:❑.,,•DESTRUCTION ❑ ii44o septic system permitted if public sewer is <br /> " <br /> r. �t available within 200 feet.)Installation will serve: Residence— Commercial— Other � <br /> .d <br /> NuAber of living units: Number of bedrooms � + <br /> Character of soil to a depth of 3 feet: • rte:r Water table depth + <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. El .4 i <br /> +F Method of Disposal <br /> '1. Distance to nearest:-...,rWell Foundations 'S Property Line A- w ± <br /> LEACHING DNEE ❑ %No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> 4 � <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS El Distance to nearest: Well Foundation .,Property Line <br /> DISPOSAL PONDS ❑ r <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 f <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perfofmance 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 /> 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 applicant m i3calAr all required inspections;,Comj4ete drawing on reverse side <br /> Signed •' <br /> Titre: f Date: <br /> FOR DEPARTMENT E ONLY t <br /> Application Accepted by /r //t� t <br /> ate V- Area <br /> Pit orgunspection by Date Final Inspectron by <br /> j Date <br /> Additional Comments: <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 <br /> INFO CASH RECEIVED BY., DATE PERMIT'NO. js9 <br /> +EH 13-24(REV.14!83) <br /> EH 1428 a, �A 3 S 7 i <br />