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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT MID <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N D ?,F-:,r <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED l <br /> a _ (Complete in Triplicate) <br /> r <br /> Application is hereby made to the San Joaquin Local Health District fora ' <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forcwell/dpump and the Rules R in desc This application is <br /> t Local Health District. 1 Regulations of the San Joaquin <br /> l Job Address <br /> d� City�S_%� fV Lot Size PM <br /> d r <br /> Owner's Name Address 1 1_'. Phone - {F <br /> 'i <br /> Contractor. OiGS'] Address,719. 0' <br /> 7AL1,ff <br /> License No. -O Phone 43 <br /> TYPE OF WELL/PUMP: I` NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DIS L FLD, PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS " <br /> INTENDED USE TYPE OF WELL PROBLEM A CO UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ 'Gravel Pack ❑ Trac T e of Casing <br /> Specifications <br /> ❑ Public ❑ Other elta Dept of Grout Seal <br /> Type of Grout <br /> ❑ IrrigationAppro ❑ Eastern Surface eal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well`Diameter r Sealing Material (top 50') _ r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is I; Q <br /> Installation will serve: Residl`havailable within 200 feet.) i <br /> ce_ Commercial— Other - r <br /> Number of living units: II Number of bedrooms 1]{ <br /> r k <br /> Character of soil to a depth of 3 feet: ;a•' Water table depth _ <br /> SEPTIC TANK <br /> ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 11 `1 'Method of'bisposat ra <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property-Line <br /> I <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number a . <br /> SUMPS El Distance to nearest: Welt Foundation Propertq�Line <br /> DISPOSAL PONDS ❑ II. <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 Ind <br /> rules and regulations of the San(Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following. I certify ll <br /> employ an " rtify that in the performance of the work for which this permit is issued;I shall not <br /> p y y 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,I shall employ <br /> tion laws of California." II P Y Persons subject to workman's compensa- <br /> I -4 <br /> app mu t c f I required inspections. Complete drawing on reverse side. <br /> Signed Title: — <br /> �� .. bate: <br /> F ART,MENT USE ONLY <br /> ti Application Accepted by <br /> aArea <br /> p-, <br /> V <br /> Pit or Grout Inspection b II Date Final Inspection by <br /> Date <br /> Additional Comments: I \fes - <br /> ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 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 AMOUNT`DUE AMOUNT REMITTED <br /> INFO RECEIVED BY DATE PERMIT NO.' <br /> + EH 13.21 rREV.1/e 5) 3 <br /> EH 1426 <br />