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j F <br /> .s <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 /> I� (Complete in Triplicate) <br /> I 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 fell City L00 Lot Size 3'To IQC -- PM <br /> a�/q 19h3 Phone 33 7••J� "� <br /> Owner's Name Address <br /> ` .. <br /> OPhone <br /> r � <br /> 1 Contractor Address C/ License No.: <br /> r TYPE OF WELL/PUMP: 'NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Cl OTHER ❑ F <br /> 1 <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 Dia. of Well Casing <br /> # <br /> E-1 Domestic/Private ❑ Gravel Pack LITracy Type of Casing Specifications —C <br /> ❑ PubliIc ❑ Other Ll Delta T Depth of Grout Seal Type of Group <br /> .. - _ <br /> I ! Irrigation �_Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done 'LlType of Pump H.P. State Work Done <br /> {, S Well Destruction ❑ Weil Diameter Sealing Material (top 50'I <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION Ar DESTRUCTION l 1 (No septic system permitted it public sewer is <br /> r available within 200 feet.) I.� <br /> j Installation will serve: Residence er Commercial Other M*0 _ <br /> Number of livi g units: - Number of bedro s_..�_ ty f <br /> Character of soil todepth of 3'feet: ` h Water table depth r <br /> f SEPTIC*TANK ❑ Type/Mfg Capacity No. Compartments <br /> ' PKG. TREATMENT PLT. 1711Method of Disposal <br /> l Distance to nearest: Well Foundation Property Line <br /> ' <br /> LEACHING LINE & Length of lines 1 QB 4 Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation �Q i Property Line <br /> SEEPAGE PITS_ l 1, Depth Size _ Number <br /> 1 SUMPS L71 Distance to nearest: ;Well Foundation Property Line <br /> DISPOSAL PONDS ❑" <br /> I hereby certify that I have prepared this application and"than the work will be done in accordance with San Joaquin county ordinarices, 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: '('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 /> I certifies the following: "1 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." i; <br /> The applicant must call for all re ired inspections. Complete drawingFan reverse side. f <br /> Signed X Title: to 40 AL Data: <br /> FOR DEPARTMENT USE ONLY / <br /> ' Date Area <br /> Application Accepted by <br /> Pit or Grout inspection by , Dated-1 4 • i' Final Inspection by Date <br /> k <br /> Additional Comments: <br /> ❑ Stk :466-6781 ❑ Lodi 36.9-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> 1 IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH -24131EV.1ie51 <br /> 14 <br /> EH 142e y <br />