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-7 <br /> = APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT (� <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) W-f754 Lshr&V 2� <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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District, <br /> 3 <br /> City <br /> Job Address`(, Lot Size PM <br /> _', <br /> Kf ddress Phone <br /> i <br /> Owner's Name <br /> �A <br /> Contractor Address <br /> License leo. Phone <br /> TYPE OF WELL/PUMP, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom �-,C] Manteca f Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy } Type of Casing Specifications - <br /> Is r <br /> 11 Public ❑ Other C�-.Qelta •� Depth of Grout Seal Type of Grout <br /> s 1J" <br /> I 1 Irrigation ---Approx. Depth W t.1 Eastern Surface Seal Installed by e} <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ V+ <br /> Well Destruction 0 Well Diameter '`Sealing Material (top 50') r <br /> Depth { Filler Material (Below 501 J- <br /> 1 TYPE OF SEPTIC WORK: NEW INSTALLATION 11j`REPAIR/ADDITION l I DI=STRUCTION (No septic system permitted if public sewer is <br /> I available within 200.feet.l . <br /> Installation will serve: Residence Commercial— Other <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. ❑ j Method of Disposal <br /> e <br /> Distance to nearest: Well Foundation Property Line <br /> � r r <br /> LEACHING LINE ElNo. & Length of lines I Total length/size <br /> FILTER BED .!I ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth i. <br /> Number <br /> I SUMPS !I L1 Distance-to-nearest:�• - <br /> Well- - �= Foundation Property Line <br /> DISPOSAL PONDS ❑ ° <br /> i 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 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 <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." �a k <br /> The applicant ust call for all re it d inspections. Complete drawing on reverse side. <br /> Sign ed X D Title: <br /> , <br /> FOR DEPARTMENT"USE ONLY <br /> Application Accepted by <br /> Date Area <br /> 4 Final Inspection by Date Date f! <br /> Pit or Grout Inspection by r. , <br /> Additional Comments: d c1 rA t A V` d C r S r <br /> _.....-❑ Stk-466-6781--«-w ID Lodi-369-3621- - ❑-Manteca 3-7104�=- -Q Tracy-'835- 5 <br /> Applicant - Return311 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.;Bax 2009,Stk., CA 95201 <br /> FEE" AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY µ DATE PERMIT NO. <br /> INFO -31 <br /> Ig <br /> Yry�, <br /> +.EH 13-24(REV,1/145) I� ! - I33 <br /> EH 1426 <br />