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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA (1J <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> -fes <br /> Job Address <br /> City -4 l Lot Size G/` <br /> t° PM <br /> Address /i/9>4�/k c� - Phone y�. <br /> V 2:717 <br /> Owner's Name <br /> Contractor aw IV wa Address /L3 License No.�; ,74(,/--Phone <br /> I <br /> TYPE!OF WELL/PUMP: NEW WELL WELL,REPLACEMENT DESTRUCTION L1 <br /> �k - '` PUMP"fNSTAL`L`PTION`i SYSTEM-REPAIR-E] �—OTHER ❑ <br /> t ;DISTANCE TO NEAREST: .SEPTIC TANK '7b SEWER LINES 7s,4-1 DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _�6 OTHER WELL PITS/SUMPS <br /> h, <br />' INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Ll Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private Gravel Pack Ll Tracy Type of Casing Specifications <br /> r f 7 Public f� Other [l Delta Depth of Grout Seal _r Type of Grout <br /> 1 lit'igaiion w _..Approx, Depth I I Eastern Surface Seal Installed by N.oJY�R <br /> l Repair Work Done ❑ Type of Pump __ .-. H. – State Work Done <br /> Well.Destruction ❑ Well Diameter Sealing Material (top 501 <br /> II Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 1 1 DESTRUCTION I 1 Mo septic system permitted if public sewer is <br /> qq available within 200 feet-1wtWybc�� <br /> I <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms .- <br /> 1; "` Water table depth <br /> Character of soil to a depth of 3 feet: r_ <br /> SEP IC TANK El .Type/Mfg <br /> )E I at Capacity_ No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> "Distance to nearest: Well foundation`` Property-Line <br /> LEACHING LINE ❑ -No. & Length of lines Total length/size <br /> t <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> ` r SEEPAGE PITS C 1 Depth Size Number <br /> j SUMPS Cl 'Distance to nearest: Well .E Foundation ai Property Line <br /> DISPOSAL PONDS ❑ , <br /> M 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 /> y` rules and regulations of the San Joaquin Local Health Dihtrict. <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 <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 /> Thai <br /> l applicant must cal for all required in cti s. Complete drawing on reverse side. <br /> '!� Title: Date: <br /> Signed X <br /> DEPARTMENT USE ONLY {� Go 9 <br /> Date Area <br /> Application Accepted by ` <br /> li d <br /> Pito Grout nspection by Date Final Inspection by Pate <br /> Additional Comments. <br /> r <br /> ;$ ❑lIStk 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, Sik., CA 95201 <br /> I FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 1324(REV.t i x sl <br /> EH 14-28 <br />