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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone Q09) 466-6781 t ' <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED" I <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$�r�/!�ruin unty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. // f <br /> A&E �� Cit Lot Size r PM <br /> Job Address Y <br /> Owner's Names" - Address t - Phone <br /> ContractorlG - ` F �ddress License No ✓ PhoneTJ�� , <br /> TYPE OF WELL/PUMP: NEW WELL ❑t WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TAMCy_ .._Y SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION-----', AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE-OF-wr=nL­s PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia: of,Welj Excavation Dia. of Well Casing <br /> El Domestic/Private El Gravel Pack 1�-CI".Tracy Type of Casing' Specifications' <br /> F1 Public t 1 Other ❑Delta Depth of Grout'Seal Type of Grouts t <br /> it I Irrigation -Apprdx, Depth ; I 1 EasternSeal Installed by "• '' - _ <br /> i i - - - -g <br /> Repair Work Done ❑ Type of Pump H.P. - State Work Done <br /> a. <br /> Well Destruction _ ❑, Well Diameter `" `� Sealing M9terial (top 501 <br /> s*Depth we �� ,Filler-Material (Below 501 <br /> TYPE OF SEPTIC WORK:.1E NEW INSTALLATION I REPAIRlADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet-) <br /> Installation will serve: Residence Commercial�' O' er J /i CNA+� ° <br /> Number of living units: ,Numberfof bedrooms `�_1" _ 41 i <br /> ( Character of soil to a depth of 3 feet: / Water table depth <br /> !f SEPTIC TANK 0 Type/Mfg Capacity 1205 No. Compartments <br /> PKG. TREATMENT PLT. ❑—., /r�� k Method of Disposal <br /> } Distance to nearest: Well GIL0 D Foundation_Zp Property tine <br /> LEACHING LINE ❑ No. & Length of lines Total lenqth/41_e___ Jt <br /> FILTER BED ❑ Distance to nearest: Well Foundation Line <br /> undation T ` <br /> (� ' t <br /> SEEPAGE PITS l I Depth 2 Size Number <br /> SUMPS 0 Distance to nearest: Well 4 Foundation 2 .Property Line <br /> DISPOSAL PONDS ❑ f <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 t <br /> f 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 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 i <br /> i certifies the following: "I certify that in the performance of the work for which this per"tLis issued, I shall employ persons"subject to workman's compensa- <br /> tion laws of California." <br /> The applicant u�st call f II required inspections. Complete drawing on reverse side.¢ -L <br /> SignedTitle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 21,_ Date s fir. _ Area <br /> Pit or Grout Inspection by Date Final Inspection by , Date 0 0 <br /> Additional Comments: + <br /> l 0 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 i <br /> k <br /> i <br /> P FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO. <br /> r INFO �f <br /> + EH1324(REV.i/x5) <br />' C EH 14-28 <br />- f - ^` � <br />