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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> + 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781" <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to cowstruct 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 / eleyu E2h g City_ LotSir <br /> ze PM <br /> Owner's NameAddress f Phone 'c �` Z9 +� <br /> Contractor /�'OF9e f '� f ' Address �- —ft License No. phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLAT 10N,1!Wif'}it -'! ///�IY�gTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPPT,I,C TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> OUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 0 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f"1 Public P Other F] Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by T <br /> Repair Work Done .❑ Type of Pump ' H.P. _ State Work Done <br /> Well Destruction 1-1Well Diameter Sealing Material (top 50'I �•`/,N 12!a?,i, E fyt j � II <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION 1:1 REPAIR/ADDITION II DESTRUCTION i l (No septic system permitted if public sewer is <br /> Installation will serve: " <br /> . Residence_ ^Commercial available within 200.feet.) <br /> Other V <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth l7� <br /> SEPTIC TANK ❑: Type/Mfg""—" »-Ca acts <br /> l Y No. Compartments <br /> PKG. TREATMENT PLT. 01 i <br /> 1( Z- Method of Disposal <br /> Distance to nearest: Well Foundation ! <br /> Property.Line <br /> LEACHING LINE El Nos&-L-engthlof lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS # �'3 '•3t i <br /> I1,I Depth t Size - Number <br /> SUMPS L; Distance to nearest: ` Well Foundation Property Line ! <br /> DISPOSAL PONDS <br /> �_"I h6eby certify,that 1 have;prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, d <br /> t _ 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, 1 shall not <br /> employ any person in such manner as to become subject to workman's compansation 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." gt 1 <br /> The applicant o ail re fired i spections. Complete drawing on never fide. j <br /> Signed X <br /> Date: <br /> r FOR DEPARTMENT USE ONLY _ <br /> e C40Applicatipn Accepted by � f N � � � Date L� �g� Area <br /> r <br /> Pit or Grout Inspection b t $ I <br /> Y t Date Final Inspection by Date —+��' <br /> Addis oneComments: t—s-`*-. <br /> �. <br /> Stk 4G6-6781 ❑ 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 /> INFOFEE AMOUNT DUEAfuIQLINT REMITTED- CK . RECEIVED BY <br /> t -• CASH s DATE PERMIT�NO. <br /> +"EH 1rs <br /> -241REV.ii5l <br /> EH 144-26 <br /> r <br />