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,A T <br /> APPLICATION FOR PERMIT pG 1VD <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 'R <br /> 1601 E. HAZEL T ON AVE.; STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> - 1PERMIT EXPIRES 7 YEAR FROM DATE ISSUED NMN�A�CES <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. AN:; <br /> Job Address �/ ��-, �h/� City Lot Size PM <br /> Owner's Nam�L�!!7�` Address- �- Q Phone <br /> Contracto,/ Address��y-� �I�1,License No.WZM20 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT E] DESTRUCTION <br /> PUMP INSTALLATION K SYSTEM REPAIR OT R f <br /> DISTANCE TO NEAREST:' SEPTIC TANK SEWER LINES z DISPOSAL FLD. P. LINE t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. apell Excavation Dia. of Well Casing t <br /> Domestic/Private ElGravel Pack. El Tracy Type;of Casi g`�: i Specifications kqq <br /> n � :I <br /> 171 Public Q Other ❑ Delta Depth of Grout Seal _• <�„ �"`*' Type of Grout <br /> ❑ Irrigation __Approx.,Depth ❑-Eastern '•'""'Surface Seal Installed by i <br /> ,,� <br /> Repair Work Done i. Type of Pump„ 'T.H.P. �I { State Work_.Done_- <br /> f% <br /> Well Destruction El Well Diameter Sealing Material (top 501 ' <br /> Depth- Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION-Ll REPAIR/ADDITION ❑ 'DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available 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: 4 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ,s <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> 'Distance to nearest: Well foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines -.;#notal length/size <br /> FILTER BED ❑ 'Distance to nearest: Well 4 Foundation Properly Line <br /> ai <br /> SEEPAGE PITS ❑ Depth F Size ) Number <br /> SUMPS ❑ Distance toynearest: Well Foundation Property Line t �' <br /> DISPOSAL PONDS ❑ '�• s a' �t�{ � e '� 1. �' <br /> I hereby certify that I:have prepared this application.and that the work will be done in accordance with Sas`'1.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 wor�Tc fors ich 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."don`tractor'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 compensa- <br /> tion laws of California." ; i The applicant must call or all required inspections. Complete drawing orLreverse side. 1'~ <br /> Signed XTitle:�� ^� bate: AA <br /> ,i <br /> RTMENT USE ONLY <br /> �a - -.._-. <br /> Application Accepted by ytA Date r <br /> Pit or Grout Inspection by, Date Final.Inspecti <br /> Additional Comments: <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMITNO. <br /> INF <br /> + EH1324lREV.t/d5) C <br /> Ek 14-28 V7 L 111 <br />