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APPLICATION FOR PERMIT 4 A. <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. J / i� <br /> Job Address -, e/ Citq��-�`'' ' Lot Size PM <br /> Owner's Nam a !/ /A 1�/ ��"�/"' Address Phone <br /> Contract" dt 6e �D�7 Address � 4 �• Dr/ License Nth? le Phon� 3 �a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO%.< <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE ELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL P EA CONSTRUCTION SPECIFICATIONS <br /> LJ Industrial ❑ Open _ ❑ Manteca Dia._of.Well-Excavation, Dia. of Well Casing <br /> ❑ Domestic/Private ravel Pack ❑ Tracy T Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irriga on ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. _1'State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler-Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.❑ REPAIR/ADDITION ❑ DESTRUCTIO (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'bedtooms <br /> Character of soil to a depth of 3 feet: ► ` ': Water table depth <br /> SEPTIC TANK fS, ❑ Type/Mfg f ` —�--Capacity _ No. Compartments <br /> PKG. TREATME T PLT. ❑ 1 Method of Disposal <br /> t <br /> Distance to.nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance toInearest: Well ^Foundati6n Property Line <br /> SEEPAGE PITS ❑ Depth { Size _ Number` <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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 /> Homeowner 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> 5 <br /> The applicant m call for all required 'nspecti ns. Complete drawing on reverse side. I <br /> + .1 [�„ - <br /> S <br /> Signed Title: �" Date: <br /> FOR DEPARTMENT USE ONLY <br /> 'R 4 <br /> Application Accepted by Date Z Area a <br /> Pit or Grout Inspecti Date Final Inspection by i Date Q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354iW5 <br /> 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 t��rAM7OUNT REMITTED S RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324{REV.t/a5) Z "7� - —,: ,3 <br /> EH 1428 fJ <br />