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I � ' <br />. i APPLICATION FOR PERMIT - �- <br /> l <br /> -= SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIREe'l YEAR FROM DATE ISSUED <br /> k•i :(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. Thos application is <br /> made H compliance with San Joaquin County Ordinance 549 forsewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> 3 . w <br /> Job Address r< °= <br /> City 175' %cJv Lot Size s QPM p <br /> II� <br /> Owner's Nameis'j/g .S /�CJ��✓/�Address " ��� T�S' �' <br /> Z, -� Phone. <br /> ys . <br /> Contractor — °'. <br /> I Address J <br /> TYPE OF WELL/PUMP: License No. TPhone <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ElJ SYSTEM REPAIR EDOTHER E3 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. OP- LINE <br /> DATION AGRICULTURE WELL O LL PITS/SUMPS <br /> _ <br /> INTENDED USE TYPE OF WELL ONS ON SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Q Manteca ia. of Well x <br /> ❑ Domestic/Private ❑ Gravel Pack Dia. of Welling, <br /> ❑ T f Type of Casing <br /> ❑ Public ❑ Other t Specifications <br /> Delta Depth of Grout Seal of Grout <br /> ❑ Irrigation app , epth ❑ Eastern J <br /> I Surface Seal Installed by ? <br /> Repair Work Done ❑ T of Pump H p 1•; <br /> State — i <br /> Well Destru .Work Done <br /> ction Weplt Diameter Sealing Material (top-501) <br /> Filler Material (Below 501) Ji �1 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION El DESTRUCTION (No septic system permitted if public sewer is <br /> I I'' vailable within 200 feat.) <br /> Installation will serve: Aesidelnce— Commercial_ Other <br /> Number of living units: ��, Number of bedrooms <br /> Character of soil to a depth of�3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. LJI ." No. Compartments <br /> Capacity_'` <br /> Method of Disposal <br /> Distance to nearest: Well :- Foundation � <br /> Property Line P <br /> .mow s ...:p: . ,� w <br /> LEACHING LINP('<"` ❑ No. &Length of lines �f �" <br /> FILTER BED i` Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ belth v - <br /> p Size Number <br /> SUMPS. ❑;. Distance to nearest:- Well Foundation <br /> ` <br /> DISPOSAL PONDS E3 !� Property Line <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. <br /> Home owner or licensed agent's signature certifies the following: '9 certify that in the <br /> employ any person in such manned as to become subject to workman's,compensation Iw soof California."rmance Contractor'work for slhiringl oPsub-contracting ermit is l signature <br /> tion certifies the following."I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant 1plustcallr all squired inspe ions. Complete drawing on reverse side. <br /> X <br /> Signed X ` " .. <br /> Title: Date: <br /> 4v .. .. _ SII <br /> j FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Ih DateArea C/ <br /> Pit or Grout Inspection by <br /> :Date Final Inspection by / 'rDateAdditional Comments: �� 77� ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104, ❑ 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 INFO AMOUNT bUE �AMOUNT REMITTED CK <br /> B RECEIVED BY DATE PERMIT'NO• I�I <br /> + EH 13-24 MEV.i i s sl � � - L <br /> EH 14-26 <br />