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APPLICATION'FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> 4- Owner's Name ddrr sy,-t`, �A - r Phone <br /> Contractor Address ` Lice'nse Na. `Phone L Z <br /> f 4 TYPE OF WELL/PUMP:, _ NEW WELL ❑ R < WELL REPLACEMENT ❑ DESTRUCTION ❑ Y <br /> PUMP INSTALLATION ❑ t S STEM REPAIR ❑ OTHER ❑ <br /> t DISTANCE TO NEAREST: SEPTIC TANK'-. X47 ySEW RLI DISPOSAL FLO. t PROP. LINE <br /> r FOUNDATIONS AGRI U URE WELL OTHER WELL PITS/SUMPS <br /> i <br /> r <br /> INTENDED USE TYPE OF WELL `1� PROBLEM A A CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom ❑ Mantec Ria. of Well Excavation ' Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> M Public Cl Other R De a Depth of Grout Seal I "' �^''r Type of Grout _ <br /> I I Irrigation _--Approx. Depth I 1 stern Surface SealInstalled by-- <br /> Repair <br /> y Repair Work Done ❑ Type of Pump State Work Done - <br /> t Well Destruction El <br /> ,Well Diameter S .ling Material (top 50') t ' <br /> zu w <br /> i � Depth t Filler Material f8elow'50'f <br /> TYPE OF SEPTIC WORK: NEW INSTAL N I REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is. .J <br /> 4 `^, ' available within 200 feet.) = <br /> Installation will serve: ;'Residence .,.4 Commercial Oth s <br /> Number of living units.: Number of bedroomstS �--- - r + <br /> Character of soil to a depth of 3 feet: on 19 0 J Water table depth <br /> SEPTIC TANK Q-=.Type/Mfg °p capacity_L219L No. Compartments <br /> PKG. TREATMENT PLT. ❑ ! ## Method of Disposal <br /> Distance to nearest: Wellsfbes Foundation Property Line J0 t -..-__... <br /> 1 ' <br /> 4 LEACHING LINE --.❑ No. & Length of lines Total length/size <br /> FILTER BED O Distance to nearest: WnIK3 Q Foundation�_ Property Line <br /> SEEPAGE PITS 1 1 t Depth Size Number <br /> SUMPS ❑ Distance to ne rest: Well Foundation Property Line <br /> DISPOSAL PONDS ­0 h <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 Joaquin Local Health District. - q <br /> ' Home owner or(icer sed 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 work'man'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." { 1 <br /> The applicant ust call fort',required 'nspections. Complete drawing on reverse side. <br /> Signed X <br /> j ,Title: s - Date: a <br /> OR DEPARTMENT USE ONLY 11 <br /> Application Accepted by 'T AA I r Date ;L f Area <br /> Pit or Grout Inspection by Date Final Inspection by Date—1 3 <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-21(REV.t i n 5) `"A - t <br />