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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 wevpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> ` I <br /> Owner's Name k) Address _L `S8 r �€S_ Phone <br /> T <br /> kIC'onlractor f V C v4 L Address �-a✓Tri} D License No._ Phone_ <br /> E OF WELL/PUMP: w. NEW WELL, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> ry PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. 1 AG ULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> ❑-Domestic/Private ❑ Gravel Pack ❑ Tracy T e of Casing -- Specifications <br /> Pu <br /> I'1 blic Cl Other n Delta r Dept of Grout Seal r. Type of Grout _ <br /> { I i Irrigation Approx. Depth i I`Eastern rSurface Bal Installed by - <br /> Repair Work Done LJ Type of Pump "H.P. - State Work Done <br /> Well Destruction ❑ Well Diameter a Sealing Material (top 50') <br /> 3 Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK! NEW INSTALLATION 1.1 REPAIR IADDITION. I I DESTRUCTION INo septic system permitted if public sewer is <br /> =� vailable within 200 feet.) (� <br /> ¢ Installation will serve: Residence Commercial--Other-- <br /> - 5 <br /> Z Num,�ber ofaivirig units:.... . _Number of.bedrooms f <br /> Character of soil toga depAh of 3 feet: Water table depth <br /> SEPTIC TANK;! D Type/M Capacity No. Compartments <br /> PKG:°TREAT) NT PLT. © r Method of Disposal <br /> "'-A�_ <br /> Distance to nearest:,-x---._Well Foundation Property Line <br /> t7LEACHING LINEF- D #`No, & ngth of lines yJ Total length/size <br /> FILTER BED ❑.. Distance to Barest: Well Foundation Property.Line <br /> SEEPAGE PITS I I'''"t5ttl -„ Size Number <br /> SUMPS Distance.to nearest: - .Well Foundation Property Line. <br /> DISPOSAL PONDS ❑ <br /> Ihereby certify that I have prepared this application and that the work will be done in accordante 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, I shall not <br /> employ any person in such manner as to becomesubject 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 /> t tion laws of California." <br /> The applica m t cal f ail required inactions. C plate drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> r <br /> Application Accepted by - j "'�" Date �� -�' — Area a. <br /> / <br /> Pit or Grout Inspection by Date Final Inspection by_ Date L <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 O Manteca 823-7104 ❑ Tracy 835166385 <br /> Applicant- Return all copies to: Environmentai Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-241REV.r/H5Y /s - <br /> EH 1a-28 <br />