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' APPLICATION FOR PERMIT <br /> i SAN JOAQUIN LOCAL HEALTH DISTRICT, <br />' 1601 E. HAZEL,TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br />! PERMIT EXPIRES.TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is helehy made to the San Joaquin Local Health District for a permit to construct and/or install the work herein dekcribed. This\ ion is <br /> i made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations� �'Jo <br /> Local Health District. aquinCl��tS <br /> Job Address <br /> Cit ' <br /> Y Lot Size ,PM <br /> -- s / .•,Jt- , <br /> Owner's Name > /= Address Phone��L7 <br /> Contractor f.- �- ]-{ AddressS,_ ! <br /> License No.U 2- Phone <br /> TYPE OF WELL/PUMP. NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA ION ❑ 'SYSTEM REPAIR ❑ OTHER ❑ <br />-,.---��t,,ISTANGE�TO�NEAR�ST::SEP71C T-ANK��O� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC <br /> ❑ Industria! ❑ Open Bottom 11 Manteca Dia. of Well Excavau Dia. of Well C ! <br /> asing q <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing �y Specif&lions C r <br /> ('i Public C1 Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> I:I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done, ❑ Type of_Pump -H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I.] DESTRUCTION l I (No Septic system permitted it public sewer is <br /> �f <br /> . Installation will serve.-' Residence_ Commercial available within 200 feet.) <br /> _ Other <br /> '" Number of living units: Number of bedrooms <br /> Character of_soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> ..-JAethod of Disposal ) <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of linesi <br /> Total length/size T-1 . <br /> FILTER BED 1 6; Distance-to nearest: Weil Foundation <br /> Property Line -4 <br /> SEEPAGE PITS I I Depth Size <br /> ' - Number � <br /> 4" 5t1MPS '� •~�L��Dis asto nearest-— _ t <br /> DISPOSAL PONDS ❑ - <br /> 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 /> 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 shalt 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 /> The applicant call for al re uired inspections. Complete.drawing onre rse side. <br /> Signed X <br /> Title: Date: <br /> FR D PARTMENT USE ONLY f� <br /> ' Application Accepted by Z— <br /> ���� Date Area <br /> Pit oriGroi,t inspection by� pec <br /> Date Final inspection by <br /> �// Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369-36.21 p"jW inteca 823-7104 ❑ Tracy 835-6385 / <br /> Applicant - Return all copies to: Environmental Heajth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE `AMOUNT DUE AMOUNT REMITTEDCK 4 <br /> ,. INFO CASH RECEIVED BY DATE PERMI7'NO j 4 <br /> +.EH 1324(REV-I/n 51 ?�F ©/1 - <br /> E14 14-26 V UVJ <br /> ` j <br />