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IIS <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LiCAL HEALTH DISTRICT <br /> I <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (COrnpll to in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District fo'r a permit to construct and/or install the work herein described. This application is <br /> made incompliancewith San Joaquin County Ordinance No.549 for se�vage or No. 1862.for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Districts <br /> Job Address - City •` Lot Size " PM <br /> Owner's Name aAddress ` ! Phone <br /> Contractor "&'� 1 x Address -License No. ��� Phone <br /> .)TYPE OF WE LL%PUMP: NEW WELL ❑ WtLUREPLACEMENT ❑ DESTRUCTION E) 9 ,� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> - ❑ Industrial ❑ Open Bottom; ❑ Manteca a ;Dia. of Well Excavation Dia. of Well Casing <br /> # El Domestic/Private d - ElGravel Pack [__1Tracy Type of Casing t Specifications <br /> M Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout 4 _ <br /> I I Irrigation Approx. Deplti' `I'I—Fri-" ' " Sdrfa"ce Seal`Installed"by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction' ElWell Diameter Sealing fi!latenaI (top 50') j <br /> v Depth ' Filler Material (Below 50') - <br /> 11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (y REPAIR/ADDITION LI DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.l.t <br /> Installation will serve: Residence r Commercial Others"I� _ { <br /> Number of living units: Number o/�bed`roms--y� jr3 <br /> �'! ° Water table <br /> Character of soil to�.a depth of 3 feet: depth- <br /> SEPTIC TANK ❑ Type/Mfgf1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r!i _ Method�f DisRosal <br /> r Distance to nearest: Well /may Foundation Property.Line}/ r <br /> vLEACHING LINE.R1 -' ❑ No. & Lengthoflines (fie Total length/size <br /> FILTER BED ❑ Distance to nearest: WellFoundation u ? <br /> Property Line <br /> Y ; <br /> SE GE PITS CL Depth Size Number OW <br /> /SLOP ❑ Distance to nearest: Well` ` li Foundation Property Line <br /> ,,DISPOSAL PONDS ❑ $ `y <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 c rtify thatfin the performance of the work for which this permit is issued, I shall not <br /> employ an " t' '� <br /> p y y person m such manner as to become subject to workman's compensation_laws_of'Califorriia."'Contractor's hiring orsub;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 /> T plies♦ t m st'call for all required inspections. Complete drawing on reverse side. <br /> Signed !Title:l d�Z���'f.�G. ► Date: ' <br /> FOR:DEP MENT USE ONLY t'� s <br /> Application Accepted by e Date <br /> Pit or Grout Inspection by Date Final Inspection by !' Date <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.0.."13ox 2009, Stk., CA.95201 <br /> FEE <br /> CK 0 <br /> INFO AMOUNT DUE. "'AM <br /> ,FOUNT REMITTED CASH RECEIVED-BY--- ^/� DATE"-- ""PERMIT•NO-' <br /> +.EH 13-24(REV <br /> -ZB - ev 6 �J� { / a C <br /> EH 14 r <br /> k <br />