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LAPPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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 1 <br /> dLocal Health District. __ ,�,,, -- ee� <br /> di 'Address . - atA <br /> City Lot Sizev) -LO PM <br /> i <br /> Owner's Name N�� AAddress0 <br /> S <br /> Phone <br /> Contractor / r —Address ,r L No3R�Phone -51ty <br /> TYPEFOF;WELL/PUMP: r% .NEW WELL 0 WEL-LfREP,LACEMENT ❑ DESTRUCTION 0 <br /> i <br /> PUMP-INSTALLATION"©, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES r DISPOSAL FLD. PROP. LINE <br /> FOUNDATION_= AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA .CONSTRUCTION SPECIFICATIONS <br /> 11 Industrial ❑ Open Bottom.- ❑•Manteca- - " Dia-of•Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private 171 Gravel Pack ❑ Tracy Type-of-Casing—T' Specifications <br /> FI Public Ll Other _E ❑ Delta Depth of Grout Seal i <br /> Type of Grout <br /> x <br /> ! I Irrigation _ q � �'-�-*�-. --� <br /> .-Approx. <br /> x.•Depth i I-Eastern—_" Surface Seal.lnstalled by Qk } <br /> Repair Work Done 0 Type of P.uump.��~� H.P. . — r State-Work Done <br /> Well Destruction E2Well Diameter Sealing Material ftop 501 <br /> Depth Filler-Mateiiai (Below 50') ar <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/_ADDI.T,ION-1 1 DESTRUCTION I }'ilNo septic system permitted if public sewer is <br /> available within 200 feet.} <br /> Installation will serve: Residence Comm Other *� _ <br /> Number of living units: _01— Number of ooms 4. 213P, RH, : l ss f <br /> Character of soil to a depth of 3 feet: u <br /> Water'Gable depth 0 '7'— <br /> SEPTIC TANK �q Type/Mfg Capacity No. Comps zfnents <br /> PKG. TREATMENT PLT. ❑ r Method of pisposai <br /> Distance to nearest: Well s5Q Foundation Q_ Property Line' <br /> LEACHING LINE No. & Length of lines L4Total length/size <br /> FILTER BEDr <br /> ❑ Distance to nearest: Well Foundation LN.mb.' <br /> Property-Cine ._, <br /> SEEPAGE PITS ` <br /> f <br /> y4 Depth Size SUMPS Ll Distance to nearest: WellFoundation / Property Line _ i <br /> DISPOSAL PONDS ❑ Aj'o <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 laws, and <br /> rules and regulations of the San J ao quin Local Health Diltrict. <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 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i <br /> The applicant m all for al ui d inspections. Complete drawing on reverse sid <br /> i <br /> Signed X _Title:. <br /> --Date: — <br /> FOR DEPARTMENT USE ONLY, I <br /> Application Accepted by/ Date <br /> ( Area- <br /> Pit <br /> Pit or Grout inspection by Date Final Inspection by If Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 0 Tracy 835-6385 E <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE A M <br /> AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 14-24 1REV,)/n 51 �CD <br /> EH 14-Zt3 <br />