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IT <br /> APPLICATION F641PERM <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 /> ?tl-vv� e�a- I, (Complete in Triplicate) <br /> p ' <br /> Application is hereby <br /> 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 a compliance with San Joaquin County Ordinance No 549 for sewage or No. 1862 for we111pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. t <br /> P <br /> City a /J2--6----tot Size PM <br /> _ <br /> Job Address <br /> � Phone , <br /> Owner's Name <br /> Address <br /> Address License No �� Phone <br /> Contractors DESTRUCTION C1TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> SYSTEM REPAIR OTHER ❑ <br /> PUMP INSTALLATION ❑ tppOP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK 'SEWER LINES <br /> DISPOSAL FLD. <br /> I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> L, industrial ED Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> Type of Casing <br /> L <br /> Domestic/Private ❑ Gravel Pack D Tracy Type of Grout ) <br /> n Other Cl Delta ` Depth of Grout Seal <br /> [-I Public - <br /> I I Irrigation <br /> Approz. Depth I Eastern Surface Seal Installed by <br /> Type of Pump H.P. 7- State Work Dane <br /> [ <br /> Repair Work Done well Destruction ❑ Wel! Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION l I DESTRUCTION l l afvailable'c system wthin 200 feetft�ed if public sewer is rr <br /> Y <br /> C y 1 <br /> Installation will`serye: -Residence=.,Commercial Other <br /> a r t r 1 <br /> E Number of bedrooms — <br /> Number of living units: <br /> _ - - Water table depth ^6 <br /> Character of soil 'toa`depth of 3 feet: No. Compartments <br /> I ❑ Type/Mf Capacity S <br /> SEPTIC TANK g - - Method of Disposal <br /> PKG. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: a Wel1Foundation <br /> A � <br /> ` <br /> Total lengthlsize - <br /> LEACHING LINE ❑ No. & Length of lines Property Line^ <br /> FILTER BED ❑ Distance t.6 nearest: Well Foundation <br /> _ Number <br /> l SEEPAGE PITS I I Depth W Size Pro ert Linen <br /> SUMPS Ll Distance to nearest: Well Foundation p Y <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, statLaws, and <br /> e <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 become subject to workman's compensation laws of California." Contraceo osiring or sub-contraciinsub'ect to workman'scompansa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p ns ! <br /> tion laws of California." <br /> The ap ' ant mu call for all req ins ns. C plate drawing o verse side. <br /> � Title: � Date: <br /> Signed X <br /> r OR DEPARTMENT USE ONLY c <br /> _ Date ' 4 Area <br /> Application Accepted by F" <br /> Final-Inspection by. Date <br /> Pit or Grout Inspection by _ Date� --.__ _ _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71174 ❑ Tracy :`835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE PERMIT NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INF <br /> 3 <br /> �7� <br /> .-EH 13-24(REV.1/115) 00 3S 1�0 <br /> EH 14-28 <br />