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ti. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> T <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 /> „ H EN_ <br /> Adds = \ 'Phone <br /> Owner's Name - � _. �t�td �' <br /> Contractor's Name ' /'11 License No. ' Phone } <br /> TYPE OF WELL/PUMP.' NEW WELL d. WELL REPLACEMENT ❑i DESTRUCTION ❑ 9 <br /> PUMP INSTALLATION ❑l SYSTEM REPAIR ❑f OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE I TYPE OF WELL PROBLEM AREA CONSTRUCTION SPILCIFICATIONSrl <br /> ❑ Industrial j ❑ Open Bottom ! Manteca Dia. of Well Excavatidn Dia. of Well Casing <br /> ❑ Domestic/Private €' ❑ Gravel Pack atracy Type of Casing Specifications <br /> ❑ Publz/,/ ❑ Other D,,Delta Depth of Grout Seal Type of Grout t_r <br /> ❑ Irrigation'/.! --Approx. Depth L Eastern Surface Seal installed by W <br /> Repair Work$one ❑ Type of Pump H.P. Ir State Work Done <br /> Well Destruction ❑ Well Diameter I Sealing Material ttop 50'1 <br /> (� Depth — Filler Material (Below 501 <br /> aTYPE OF SEPTIC WORK' NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> iJ 1 available within 200 feet.) <br /> Installation will serve: jResidence_ Commer�ial_ Other I <br /> Number of living units: Number of <br /> Character of soil.to a depth of 3 feet: Water table depth �✓ <br /> SEPTIC TANK ❑ Type/Mfg `� j Capacity No. Compartments <br /> �, <br /> PKG. TREATMENT PLT. O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ` !L Total len th/size <br /> LEACHING LINE k No. &_Length of lines g <br /> FILTER BED D Dista�e to nearest: Well F6'I. dation Property Line <br /> SEEPAGE PITS i] D pth £ { Size f L# L!r Number <br /> f E � � !e Property Line <br /> SUMPS E] Dist ce to nearest:. _ Well Foundation <br /> DISPOSAL PONDS _111 �{ <br /> I hereby cartify�that-:I have prepared thisrapplication and tAat th or will be done in acco�ridaii ith San Joaquin county ordinances,state laws, and <br /> rules and regulations of the.San Joaqui&Local Health District. <br /> Home owner o"r licensed agent's signature-oertifies,the following. "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any peison in such manner as Lo beceubjeto workman's compensation laws of Calrfornia.' Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance— faf thew ork for which this permit is issued,I shall employ persons subject to workman's compensa <br /> tion laws of Cal' rnia." <br /> "The applicant 1�call for a6 required inspections{ComvletWrawing on reverse side. ' <br /> 1 j Title: Data: W <br /> Signed I ., <br /> "FO� EPARTMENT USE ONLY <br /> Application Accepted tly <br /> at Area <br /> Area <br /> 4 <br /> Pit or Grout Inspection by Date Final Inspection by =` Date u - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1i Manteca 823-7104 ❑ Tracy -6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-P.`O. Boz 2009, Stk., CA 95201 <br /> {-� FEE' AMOUNT DUE' AMOUNT 11wiTTED CASH RECEIVED BY DATE, PERMIT"N0. <br /> INFO. 4 <br /> F + EH 13-24IMEv. �— <br /> EH 1428 \�" s �) •�7 \ - ! ._ <br /> v _ I • <br />