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«. APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 1 'i+•`-^�+^-_ryttfL�' <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Rti 1 <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE�ISSUE6 � � <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 /> r made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 forrwell/pump and the Rules and Regulations of the'San Joaquin <br /> Local Health District. '" <br /> Job Address +,r. � �1 <br /> u +Cit of Size_-- �1[��U PM. <br /> Ow <br /> her's Name E r / Address W �' Phone <br /> :! <br /> Contractor Address License No. Phone <br /> I TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL',?-PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> r <br /> EJ Industrial --"�Open Bottom ;❑.Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ID Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of Casing Specifications <br /> ❑ Public ❑'Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth,�❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump �' ',�'. H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth' Filler Material (Below 450'I <br /> k TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑t DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other ' <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/MfgCa aci <br /> P tY No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> 6 FILTER BED <br /> ❑ Distance to nearest: Well Foundation 'Property Line <br /> r SEEPAGE PITS ❑ Depth Size <br /> r <br /> Number <br /> ' <br /> SUMPS S ❑ Distance to nearest: Well -- Foundation *Property Line <br /> DISPOSAL PONDS ❑ ., <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: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> h..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, I shall employ persons subject to workman's compense- <br /> aws California." <br /> The applica t all for all re ctionsmplete drawing on reverse e. <br /> r <br /> Signed X f.. Title: G9[Uscr �S <br /> Date: <br /> FOR DEPART USE ONLY <br /> Application Accepted by Date Area C�/, <br /> p <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: a{ <br /> ❑ Stk 466-6781 'LJ Lodi .369-362f ❑ Manteca -7104 ❑ Tracy 835.6385 <br /> w Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH""- RECEIVED_BY DATE�, f PERMIT'NO. <br /> f <br /> EH 13-21(REV.17 115) <br /> #, EH 1428 O <br />