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4 <br /> APPLICATION FOR PERMIT $ <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 /> { (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 Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,L rt� '� " <br /> C-04 Y ;L & <br /> Job Address 7" City Lot Size PM <br /> t. - <br /> Owner's Name `_ f Address Phone <br /> Contractor 1Y8�'CJ � Address. License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ rDESTRUCTION ❑ <br /> ' — _PUMP tNSTALLATION-O - `- - -- SYSTEM REPAIR ❑ - - OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES + DISPOSAL FLO. PROP. LINK F <br /> k FOUNDATION$ AGRICULTURE WELL ^ OTHER WELL PITS/SUMPS. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f"1 Public ❑ Other l ❑ Delta Depth of Grout Seal Type of Grout __ <br /> I ll Irrigation _..Approx. Depth i I Eastern Surface Seal Installed by � <br /> Repair Work Done ❑ Type of Pump H.P. F State Work Done_ <br /> Well Destruction ❑ Well-Diameter 1�. Sealingpr, MI)Depth Filler Ma e ] <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION I l REPAIRIADDPriOl if public sewer is <br /> r r r available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other O haV8 expired Without <br /> I Number of living units: Number of b droom word( being CC7mPlated !fir ,iry�pl oUpIld � <br /> Character of soil to a depth of 3 feet: ip r W �Jf al�lrt t).glblp iepth R <br /> SEPTIC TANK Type/Mfg` Q * �m�{'h�� 9 1 <br /> 1-61apacr e " ' !-Q� Mients <br /> PKG. TREATMENT Pi_T. ❑ j �, �'"` ' "Method of Disposal <br /> q ,a, Q 7 I <br /> Distance t nearest: Well 9 -�_ Fo dation � Property Line _ <br /> LEACHING LINE ❑ No. & Length of lines ,Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> } � r <br /> t SEEPAGE PITS I I Depth Size j Number y <br /> SUMPS ❑ Distance to Nearest: Well s Foundation Property Line <br /> DISPOSAL PONDS ❑ ' W <br /> Thereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, avid } <br /> rules and regulations of the San Joaquin Local Health Dltrict:': ' I ­- .., -- <br /> Home <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.",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,,)shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The alicant st call for ail required <br /> pp q _ inspections' Corpplete drawing an rev se side. I r <br /> Signed X Ttde: Date: <br /> t <br /> I FOR DEPARTMENT USE ONLY`. <br /> Application Accepted by ` ; Date ` <7 Area 4 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: ` <br /> 0 Stk 466-6781 ❑ Lodi 369-3621 �. ❑ Manteca 823-1104'---' ❑ 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 AMOUNT DUE .' AMOUNT REMITTED`4 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO yy <br /> ..EH 13.24(REV.i/Ksi *' 1gg <br /> I <br /> EH 14-26 <br />