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I� APPLICATION FOR PERMIT <br /> I� SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> IM 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 �% I Cc/Y1 GLS City of Size PM <br /> Owner's Name (��`OQ Q /y( ( - _ yS� "Z h/C�Yl Phone ��� S� <br /> /if�� e�_ _ Address <br /> Contractor I' ` � Address License No. Phone <br /> TYPE OF WELL/PUNEW WELL ❑ WELL REPLACEMENT C1DESTRUCTION ❑ <br /> !I <br /> 'PUMP INSTALLATION ❑ 'SYSTEM REPAIR ❑ HER ❑ <br /> DISTANCE TO NEAREST:"'SEPTIC TANK' SEWER LINES D FLD. PROP. LINE i <br /> II:FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Cf� <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCTION SPECIFICATIONS ` <br /> ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of Well Casing �n <br /> ❑ Domestic/Private -�O Gravel Pack racy Type of Casing Specifications `1 <br /> f 1 Public i-fl Other y n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation 1 .- pprox. Dlepth I ] Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump .I� H,P. State Work Done_ r <br /> Well Destruction ❑ 'Well Diameter IM Sealing Material )top 501 <br /> Depth I�. Filler Material (Below 50').. <br /> TYPE OF SEPTIC WORK: , NEW INSTALLATION I:) REPAIRIADDITION l I DESTRUCTION (No septic system permitted if public sewer is <br /> aiiable within 200 feet.) <br /> Installation will serve: Residence_ Commercial T 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 CU <br /> No. Compartments <br /> PKG, TREATMENT PL 1.3 ! Method of Disposal <br /> j Distance to nearest: Well Foundation Property Line <br /> .I I� <br /> w <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED © Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1.1 Depth 4 o <br /> w p I Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 II <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. <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, 1 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 /> 'k <br /> The applica must call for! re fired ins tions. Complete drawing on reverse side. 1 Q7 <br /> (� Signed d yf Title: /�. Date: — V • <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date A <br /> Pit or Grout InspectionI Date Final Inspection by Date <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 /> 'I 'r <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT�NO. <br /> t EH -24{flEY.r/H 51 <br /> 14 <br /> EH 14-28 <br /> ° lM h <br />