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t <br /> APPLICATION FOR PERMIT 70 — <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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. wasz, <br /> City Z Lot Size PM <br /> Job Address <br /> Owner's Name <br /> �' L_ Q Address ' 1° Phone f <br /> � <br /> / � I <br /> Contractor <br /> Address License No.����7(�/ Phone <br /> TYPE OF VEL/PUMP- NEWWELL <br /> WELL REPLACEMENT DESTRUCTION ❑ <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION Fes; <br /> DISTANCE TO NEAREST: SEPTIC TANK _._.��- SEWER LINES. DISPOSAL FLD. PROP. LINE <br /> FOUNDATION �Qr AGRICULTURE WELL <br /> OTHER WELL.— PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS a_ <br /> ❑ Industrial - © Open Bottom ❑ Manteca Ria. Dia. of Well Casing <br /> of Well Excavation 9 <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casi4i if Specifications /.id <br /> �-� <br /> ❑ Public CI Other D Delta Depth of Grout Seal 7;VType of Grout <br /> I I Irrigation, 0751�r.Approx. Depth I i Eastern Sura a Seal Installed by <br /> Repair Work Done ❑ Type of Pump � H.P. --- _ State Work lDone <br /> ED <br /> ZD <br /> Well Diameter Sealing Material (top 50 <br /> Well Destruction <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRIADDITION td DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial .Other ... 1 <br /> Number of living units: Number of bedrooms ! l <br /> Character of soil to a depth of 3 feet <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg µj Capacity No. Compartments <br /> Method11 `of'.D1sposal <br /> PKG. TREATMENT PLT. ❑ <br /> i Distance to nearest: Well Foundation Property Line <br /> } A <br /> LEACHING LINE LINo. & Length of tines Total length/size <br /> FILTER 'BED <br /> ❑ Distance to nearest. <br /> Well Foundation 'Property Line t -' <br /> i <br /> t, SEEPAGE PITS ( I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation':3 '.Property Line <br /> t DISPOSAL PONDS ❑ F» <br /> r t 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 /> a <br /> i rules and regulations of the San Joaquin Local Health District. E s <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, !shall not <br /> employ any person in such manner as to become subject to workManrs-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 /> 4 ) The applicant must c for all quired inspection . Complete drawing on reverse side. ` <br /> yy <br /> 1 � Date: <br /> J` I Signed Title: <br /> k FOR DEP ARTMEN USE ONLY <br /> E r Date O ` D� t Area'- <br /> Application Accepted by <br /> date, <br /> Pit or rout nspection by <br /> Date Final Inspection by <br /> 1 Additio I Comments: ' 1� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0Manteca 823=7104 ❑ Trecy 835 6385'` <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO p —'aoiZ) <br /> �.EH 1324 I REV.i i x 51 <br /> E414-28 <br /> k <br />