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• i � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ' 1601 E. HAZELTON AVE., STOCKTON, CAS <br /> r 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 J8aquin County Ordinance No. 549 for sewage or No. 1862 for <br /> Local Health District. well/pump and the Rules and Regulations of the San Joaquin <br /> Job Address ! t� �, <br /> CityLot Size AS <br /> Owner's NameAddress <br /> Phone e3 <br /> r <br /> //ss__ 3 <br /> Contractor /✓Bid �lr/� dress <br /> icense No. Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION U <br /> 1� . <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER-.0 <br /> DISTANCE TO NEAREST:,SEPTIC TANK SEWER LINES <br /> '. DISPOSAL FLD. �PR�P. LINE <br /> FO <br /> UNDATIONAGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> i' <br /> INTENDED USE TYIPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 6 Industrial e ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ' € Dia. of Well Casing <br /> ❑ G:ravel Pack._.,,_,,,y_❑ Tracy Type of.Casing <br /> f-1 Public ❑ diner Cl Delta�' Specifications <br /> t i Depth of Grout Seal Type of Grout <br /> 1 I I Irrigation _IiApprox. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump; H.P - <br /> State Work Done <br /> Well Destruction ❑ WelllDiamete� ti Sealing Material (top 5011 <br /> Depth _l it€er Material (Below 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION, . REPAIR/ADDITION`t.I DESTRUCTION 1 1 (No septic system permitted if public sewer is <br /> t <br /> Installation will serve: Reside Commercial_ Other a, available within 200 feet.) 1 <br /> p �, % <br /> t Number of living units: Number of bedrooms <br /> Character of soil to a depth o(13 feet: 4 <br /> t Water table depth + <br /> a SEPTIC TANK❑ Typ'e4g, Ale- <br /> PKG. TREATMENT PLT. EJ -. Capacity. No. Compartments <br /> ' a -.� <br /> f ?�' <br /> Method of Disposal- <br /> y Distance to nearest: Well Foundation la <br /> .Property line J� <br /> NI <br /> LEACHING LINE ❑ NO. & Length of lines <br /> m _�,_ Total length/size Q <br /> I FILTER BED-- -� "rl—Distance to-nearest: Well <br /> ril. �_�, Foundation__ j� Property Line <br /> SEEPAGE PITS. l I Depth Size -�! ' 1 <br /> SUMPS i.y ll r— . -v Number <br /> `;Distance to.nearest: Well Foundationi". <br /> ._.: Property Line <br /> DISPOSAL•PONDS ❑ °� � "" : . A ._t1„ .� .. r 1 <br /> ' I hereby certify that I have prepaOed 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 toaquin Local Health D�trict. <br /> l• s �-: <br /> Home owner or licensed agents signature certifies the following:=.1 <br /> -certify that in the performance of the work for which this permit is issued, 1 shall not <br /> -eritploy-any_personih"such.manne'as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature i <br /> certifies the following: "I certify thdat in the performancE of the work for wm&rthis-permit is issued,I shall em to subject <br /> tion laws of California.” N� p y persons I to workman's corn pensa <br /> The apps nt must c�" q ions. Complete drawing on revePse side.r <br /> Signed X Title: <br /> r I� Date: <br /> FOR DEPARTMENT-USE ONLY <br /> Application Accepted <br /> ilk Date;? �. r ��� Area / <br /> ar Grout Inspection bybate �✓ <br /> III mal Inspection by ate <br /> Additional Comments; � ` �" r' <br /> ❑ Stk 466-6781 ❑ LodiL7 Manteca. 823-7104 ❑ Tract 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 RECEIVED BY <br /> DATE EPRMIT'N0EH 13-24(REV.I I K 5)EH It-2a '��S <br />