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APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCIKTON, CA 5 <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 ,r a permit to construct and/or install the work herein described. This application is j <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1662 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address Z City� Lot Size PM <br /> Owner's Nam �-L Address _— Phone <br /> Contractors -_,may-�-Addres License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 1-1DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE \' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS T <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom C3 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l Public n Other 1­1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _.Approx. Depth l I Eastern Surface Seal Installed by _ <br /> F Repair Work Done L] Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence_ Commercial_ Other l <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 ' '1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> R <br /> Distance to nearest: Well Foundation Property Line <br /> . r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED I_1 Distance to nearest: Well Foundation Property Line <br /> 7 <br /> SEEPAGE PITS Depth —Size_ ��A r �, Number _ <br /> SUMPS I 1 Distance to nearest: Well f Foundation _� Property Line !� <br /> 7 <br /> DISPOSAL PONDS 1.1 <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. f <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, t shall 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, t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant t tali far all required i pact ns. Complete awing arse side. <br /> 1 <br /> Signe Title: <br /> FOR DEPARTM T USE ONLY y <br /> Application Accepted by DatArea ktG <br /> Pit or Grout Inspection by Date 4/� Final Inspection by Date �J Q <br /> � � c <br /> Additional Comments: <br /> Ae- <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-5385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO '--] CASH <br /> C70 <br /> r EH 1324 IREV.1/H 51 /D /r N _ <br /> EH 14-28OLI <br />