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rs CP <br /> 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. I j <br /> ,(/Job Address . L 1 cs2Cit [ /� X r 3 PM <br /> / J Y Lot Size <br /> Owner's Name l;A !e/L/L e/Qf/9Address ` (9 !)o'T V 1 S � Phone r�Hl <br /> Contractor Address !O ' i'ense No- l <br /> ��Phone <br /> E OF WELL/PUMP: NEW WELL WELL, REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION r SYSTEM REPAIR ❑ N �P p <br /> DISTANCE TO NEAREZZ_LST: SEPTIC TANK - _ SEWER LINES DISPOS L FLD�� PROP. LINE # <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial -_--gip Open Bottom If Manteca Dia. of Well Excavation � �f <br /> Dia. of Well Casing 0'.,-_ <br /> Domestic/Private Gravel Pack D Tracy Type of Casin S� <br /> 9 �Cr Specifications <br /> M 1 Public Cl Other l l pelta Depth of Grout Seal Type of Grout ? J <br /> I i Irrigation _..Approx. De th I 1 Eastern Surface Seal Installed b nt <br /> �rl�S/� v VSA. <br /> Repair Work Done ❑ Type of Pump P. � ("'l✓ State Work Done <br /> Well Destruction ❑ Well Diameter f Sealing Material (top 50') <br /> Depth O_' -Filler Material (.Below.50') F <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 R AIWADDITION f-1 DESTRUCTI ( I (No septic system permitted if public sewer is <br /> .-A ._. . <br /> ..available within.200_feet.)__� k <br /> Y. Installation will serve: Residence Commercial r j <br /> .y . <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth z <br /> SEPTIC TANK ❑ Type/Mfg acity No..Compartments <br /> PKG. TREATMENT PLT. 0 <br /> r Met od of Disposal <br /> Distance'to nearest: Well Foundation - <br /> Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Tota ngth/size <br /> FILTER BED ❑ Distance'to nearest: Well Foundation <br /> ` perty Line <br /> - s <br /> SEEPAGE PITS I 1 Deptq ize n f <br /> = Number � <br /> SUMPS t L7 Distance:to nearest: Well ~ Foundation Property Line <br /> DISPOSAL PONDS ❑ - <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 Di§trict. ti <br /> Homo owneror 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 person son in such manner as to became subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fallowing: "I certify that ih 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 appGca must calf for a!I r�uired inspections. Complete drawing�onverse std r <br /> Signed Title: Date: <br /> ! FOR DEPARTMENT USE ONL <br /> Application Accepted by -� <br /> Date_ d` � „ Area <br /> tP­FPit or Grout Inspection by Date=' Final Inspection by <br /> - - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> - r <br /> FEE AMOUNT REMITTED <br /> INFO AMOUNT DUE CR If C H <br /> RECEIVED BY DATE PERM17'NO. <br /> S <br /> +.EH 13-24[REV.r i n 51 <br /> EH 14-2e <br /> /0fdJ <br />