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i <br /> APPLICATION FOR PERMIT <br /> ` SAN JOAQUIN LOCAL HEALTH DISTRICT. <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67811, <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. y <br /> / <br /> Job NAddress t P S City. Q f Lot Size G PM <br /> Address Phone <br /> i <br /> Owner Name <br /> rContractor ► Addressp. a+L )r License No Phone �' l <br /> , <br /> -�-��•-.«.-�WEL-L••REPLAGEMENt.X- 7 DESTRUCTION)K__�—�^Y--�•�--�°�°^"__ <br /> `-""'TYPE OF'WELL/'POMP: .�..-- ---NEW WELL-[ <br /> 1f PUMP INSTALLATION SYSTEM REPAIR ❑ OTHEI) ❑ t <br /> ✓DISTANCE TO NEAREST: SEPTIC.TANK — SEWER LINES DISPOSAL FLO.� PROP. LINE <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ! al,IN <br /> " TENDED USE TYPE OF.WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS !f <br /> I❑ IndustrialOpen Bottom C1 Manteca Dia. of Well Excavation Dia: of Well Casing {tom <br /> D ��omestic/Private ❑ Gravel Pack L1Tracy Type of Casing Specifications <br /> { I Public n Other f i Delta depth of Grout S I Tyke of Grout - <br /> NIP <br /> iE <br /> 1 1 Irrigation � �Approx. Depth I I Eastern 'S ✓face Seal Installed by <br /> Repair Work Done ❑ T� y�pe of Pump H•P• Staate� ork bone _ <br /> Well Destruction X, Well Diameter Sealing Material [top 501 <br /> t '�� h = t• r,DepthfFiller Material (Below 501�' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 RLPAIWADDITION l 1 DESTRUCTION I I (No septic system permitted if public sewer is j <br /> I I� P •� - -�-•••T E �"'" §4 available within 200 feet.) + <br /> 4 Installationwill serve: Residence_ Commercial a� Other � I <br /> r Number of-diving units:�* Mumbeer o bedrooms ! _ Ln <br /> Character of soil to a depth of 3 feet:E Water table depth <br /> +` SEPTIC TANK t ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r f <br /> Distance to nearest: Well Foundation PropertyLine s' <br /> LEACHING LINE L7 No. & Length of lines Total length/size <br /> I FILTER BEd ❑ Distance tonearest: . Well' Foundation Property-,Line <br /> SEEPAGE PITS 1 1 Depth f Size__ *� Number <br /> SUMPS L71 Distance to neai-est;---� Well_ Foundation Property Line r <br /> DISPOSAL PONDS ❑ ! <br /> I hereby certify that f have prepared this application and that She 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. f <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, l shall not? <br /> employ any person in such mariner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature1'" <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 /> I 1 #Ion laws of California:" ; <br /> ' iThb% apptica7it"rrius kali fdF all'requiFed'in`s±tions.'Campleta`drawiiig"on <br /> Signed X Title: - - Date: <br /> OR DEPARTMENT USE ONLY ' <br /> Application Accepted by Date Area <br /> r.N Pit'or Grout Inspection by Rate Final l spection Date <br /> Additional Comments: <br /> ❑IStk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-fi385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> Y I FEE MOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PER1VliT'NO, <br /> I INFO <br /> r.FiH 13-24(REV.t/y sl /v <br /> EH 14-28 <br /> i I <br />