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4 <br /> tl <br /> ,W APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTir-( <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CAS"^ <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED"' G .- <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install She,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 /> Ab�Job Address "m Ilk dr City Lot Size PM <br /> Owner's Name yAddress Phone MAIM <br /> Contractor CJUi? s� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L;i—� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> J <br /> ❑ strial ElOpen Bottom ElManteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation Approx. Depth I 1 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') ne-,l <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.I <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of b roams <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line f <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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, 1 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applict must call or I reC uir ins tions. Complete drawing on reverse side. <br /> Signed X r Title: C Date: �R <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by date / Am. <br /> **XL <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED BASH f��RE�CCEIVED BY DATE PERMI7'NO. <br /> +.EH13. UD (241REV.IiKS) 73bb YI/ C - ����2� �~3 <br /> EH 1428 1 <br />