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j1 <br /> " -� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA I <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED I <br /> (Complete in Triplicate) <br /> f h District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joaquin Local Healt <br /> h , 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. pp <br /> Local Health District. p [�o�j� C I <br /> F 1 J2, of AU®�m City �iJ',,Qr Lot Size PM <br /> Job Address � ii c y� <br /> 11 Owner's Name J���ll� s laD/�_ Address S)A Phone —q-0--6190c- <br /> Contractor <br /> hone —q-0--6190cContractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ . WELL REPLACEMENT ❑ DESTRUCTIOA PUMP INSTALLATION ❑ SYSTEM"REPAIR ❑ OTHE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> .II <br /> ,I INTENDED USE TYPE OF WELL. PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i1 ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation. Dia. of Well Casing <br /> d ❑ Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications f <br /> n Public n Other ❑ Delta Depth of Grout Seal Type of Grout—.-- <br /> I <br /> rout —I I Irrigation —.-Approx. Depth I I Eastern Surface Seal Installed by - <br /> I Repair Work Done ElType of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material (top 501 <br /> Y Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i:1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> ' Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of b drooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> f No. Compartments Capacity <br /> SEPTIC TANK ❑ Type/Mfg - <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> j� Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well un ion Property Line <br /> i, SEEPAGE PITS I I- Depth Size _ Number <br /> G SUMPS 0 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 /> j� rules and regulations of the San Joaquin Local Health Di'ktrict. <br /> Home owner or licensed agent's signature certifies the following: "I certify thatin the performance of the work for which this permit is issued, I shall not - <br /> I 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 te 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 /> �I The applicant ust call for all eqw ed insptctions. Complete drawing on reverse side. <br /> Signed X �1J �"'� "''� Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate q_'12609 Area <br /> Pit or Grout Inspection b Date Final Inspection by �� �� Date <br /> Additional Comments: <br /> Cl 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 CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> j 3S V7 >ti qpzm8q Sq-.2 <br /> Il; a.EH 13-24(REV.t/h5) <br /> EH 14-28 <br />