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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN"LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <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 la'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 <br /> Local Health District. well/pump and the Rules and Regulations of the San Joaquin <br /> a <br /> Job Address " City '"f Lot Size <br /> PM <br /> Owner's Name Address �t <br /> ContractorA3 . Addresses' f ,r�S' License No <br /> Pho <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ ne <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private Dia. of Well Casing <br /> ❑ Gravel Pack ❑ Tracy Type of Casing S <br /> ❑ Public 'r�❑ Other Specifications <br /> t ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation r� -L—Approx. Depth "❑.Eastern Surface Seal Installed by <br /> Repair Work Done ❑ *Type of Pump H.P �"4 <br /> State Work Done <br /> Well Destruction ❑ ,.Well Diameter 4 Sealing Material atop 50') <br /> ! Depth Filler Material [below 50') t; O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El Filler <br /> PO,'"DESTRUCTION ❑ (No septic system permitted if public sewer is 0 <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_At�'Other <br /> Number of living units:" 0_ Number of bedrooms 42 <br /> a I <br /> Character of soil oto a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK i�.Type/Mfg' f' I Capacity'' 0 <br /> PKG. TREATMENT PLT. ❑ -- No. Compartments <br /> Method of Disposal <br /> Distance tonearest: V41ell +t Foundation Property Line Z ad�- <br /> LEACHING LINE t ®!No. & Length of lines Total length/size'" <br /> FILTER BED, > ❑ Distance to nearest: Well t]I�L <br /> Foundation_ /jL Property Line 04 t^ <br /> SEEPAGE PITS ❑ t Depth" iSize <br /> Number' <br /> y SUMPS ❑ Distance to nearest: Well Fouhdation <br /> Property,Line <br /> DISPOSAL PONDS.' ❑ y ,,_.,, <br /> I hereby certify that:I have prepared this application and that the work will be None in accordance,with.San Joaquin county ordinances, slate laws, and E <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 A <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 em to <br /> tion laws of California." t p Y Persons subject to workman's compensa- <br /> The applicant ca for re i d inspections. Complete drawing on reverse side. <br /> ¢ t <br /> Signetf Title:_C .Gr- <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date4t;,,,Are1 <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> gpAdditional Comments: t <br /> $tk 466-6781 ❑ Lodi 369-3621 EJ Manteca 823,71 y, piracy" <br /> plicant- Return all copies to:.Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 93201 <br /> 4FEE. AMOUNT DUE <br /> INFO AMOUNT REMITTED CASH RECEIVED BY DATE, PERMIT'NO. <br /> + EH 73-24(REV.s/as) . <br /> EH 5425 <br />