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APPLICATION FOR PERMIT <br /> L SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEI_TON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 15SUED' <br /> h (Complete in Triplicate) ; <br /> .:µ. '� `L.�� '.. ., •�i * <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 Ryles and Regulations of the San Joaquin <br /> P q . <br /> Local Health District. ��. ' j s ` <br /> �lj ,yam Il•., <br /> Job Address <br /> City Lot Size PM <br /> �P CCt yx O �(� <br /> Owner's Name dress d- Phone�P <br /> Contractor Co. P_, �� Address License No. Phone <br /> TYPE <br /> TYPE OF WFLL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/ LIMPS <br /> INTENDED USE TYPE OFIWELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I <br /> ❑ Irrigation ---Approx. Depth ❑ East_ernSurface Seal Installed by <br /> Repair Work Done 15Type of Pump H.P. ""'°s State Work Done <br /> Well Destruction ❑ Well Diarndter -SealinwMaterial4top050! i <br /> D pth .h Filler Material (Beiow 50 1-'4 14 t ` � v" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONIDDESTRUCTION 12 (No septic system permitted if public sewer is C <br /> -1-available within'200 feet.) <br /> Installation will serve: Residence Commercial' Other � � <br /> Number of living units: Number of bedrooms ' <br /> i �. t I <br /> Character of soil to a depth of 3 fee!t:t: � Water table depth <br /> SEPTIC TANK El .Type/Mfg Capacity No. Compartmentsj ' <br /> PKG. TREATMENT PLT. ❑ j � `Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & rength of lines Total length/siza4 t # <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line j t <br /> SEEPAGE PITS ❑ Depth l Size " Number-- <br /> SUMPS El Distance to nearest: Well Foundation Property Line <br /> � ' e <br /> i. DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this'applkgion^and That=th`e wtirk will"be dohs if1 cordance with San Joaq-5i ire county ordinance, 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." <br /> The applica m I for al u)red inspectio Complete drawing on re rse side. <br /> Signed Title: _ Date: I <br /> i FOR DEPARTMENT USE'ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection byDate 15 <br /> I vi r <br /> Additional Comments: # ` <br /> ❑ Stk 4664781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 ❑ Tracy 83556385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED SY+ -DATE PERMIT`NO. <br /> INFO CASH <br /> + EH 13-24 rREV,1/a5) If 1416110 <br /> EH 14.26 <br />