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Alk. c —0 - <br /> 0 - <br /> ME- (L <br /> !�,J 11/��„//�� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> - Telephone (209) 466-6781 <br /> PERMIT EXPIRES-1`YEAR'FROM DATE iS§UED ' zz' <br /> (Complete iri Triplicate) <br /> t 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 i <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. <br /> Xob Address / 1�_/ city,/¢ Size'Z/y"" Ir ?�4/PM CSU,-O�� /I <br /> t �( Owner's Namey Address -10111! Pghone Je�l 1--",4'�,K50 <br /> Contracto r2ss <br /> &0 +�"'�-+'License No. 0v Phan <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ { <br /> PUMP INSTALLATION SYSTEM REPAIR E] OTHER 71 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> �.w INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I } ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ° Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> tIrrigation ---Approx. Depth ❑ astern � rface Seal Installed by <br /> pair Work Done ❑ Type of Pump H.P, State Work Done 10-W 4 <br />+ Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 , <br />} TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION C7 DESTRUCTION ❑ No septic system permitted if public sewer is <br /> _ available within 200 feet.i <br /> Installation will serve: Residence— C'o'mmercial— Other K <br /> Number of living units: Number of bedrooms <br /> • Character of soil to a depth of 3 feet: f 'Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity } No. Compartments ' <br /> ' PKG. TREATMENT PLT. ❑ Method of Disposal <br />` Distance to nearest: Well Foundation Property Line 111 <br /> i <br /> " r " <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth —S ize Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line- 'r - <br /> DISPOSAL PONDS ❑ t t <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 1 <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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 /> The applicant mu II r all requi i ctions. Complete drawing on reverse side. <br /> Signed Title A, , Date: <br /> to <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by. Date Area r <br /> ' r <br /> Pit or Grout Inspection by " Date Final Inspection by" 04 Date <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385_ <br /> f Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA 95201 <br /> - - - - g - - <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVE" BY DATE PERMIT'NO. <br /> +EH 73-24(REV.s/65) <br /> EH 14-26 <br /> I <br />