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1 (j APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE.; STOGKTON, CA <br /> \"h Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i }, <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. <br /> Jobb?Address <br /> City Lot Size pM 41- <br /> Owner's Name A Address <br /> 6' Phone <br /> Contractor alm.Address V r44, <br /> License No.4212Nr_Phone <br /> TYPE OF WELL/PUMP: NEW ELL K WEL REPLACEMENT ❑ DESTRUCTION ❑ a <br /> PUMP INSTALLATIONI <br /> 18 SYSTEM REPAIR ❑ OTHER ❑ j : <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ° <br /> DISPOSAL FLD.,42-0` PROP. LINE'1 <br /> FOUNDATION AGRICULTURE WELL J—U26 OTHER WELL PITS/SUMPS ` % <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F1 Industrial ❑ Open Bottom Li Manteca Dia. of Well Excavation.� �� fr [ <br /> _ •� Dia. of Well Casing <br /> Domestic/Private Gravel Pack ❑ Tracy of Casin _ " ' "` <br /> ' g r--- 1��. Specficationns, /d4 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ti Cl Type of Grout <br /> -9-Irrigation .-_ . . -App�x;Qepth•�.-i=]�Eastarn�..�'� Si.�face�Seahf stalled'by`� i <br /> Repair Work Done ❑ Type of —� <br /> Pump !n ; <br /> „ �- -EiH.P. } State Work Done <br /> Well Destruction ❑ Well Diameter t_ Seating Material (top 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Oi�'REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i <br /> I available within 200 feet.) € S <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms : ' j <br /> Character of soil to a depth of 3 feet: `' Water table depth <br /> SEPTIC TANK ❑ T e/Mf 1 a i �A <br /> yP g - Capacity'R: No. Compartments s <br /> PKG. TREATMENT PLT. ❑ t � V r r Method of Disposal . <br /> Distance to nearest'! <br /> j Well i 'Foundation "* Property Line r C' <br /> LEACHING LINE ❑ No. & Length of lines ) I Total length/size Y � <br /> FILTER BED ❑ Distance to nearest:1. Well - Foundation IT Property Line ` tis <br /> • t <br /> SEEPAGE PITS ❑ Depth I Size ' <br /> Number r <br /> SUMPS ❑ Distance to nearest: Well Foundation # Property Line P' <br /> DISPOSAL PONDS ❑ R _ <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 a, ` <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•I <br /> not <br /> employ any person in such manner as to become subject-to•workman's•compensation,taws-of:California."Contractor's hiring or sub-contracting- , I sha11 emlos compen <br /> ure skgnature .. <br /> certifies the following:"I certify that in the performance of the work for which,thispermit is issuedpy persons subject to workman' t <br /> tion laws of California." u, <br /> The applicant must r-alljpr all required inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `� <br /> Area <br /> Pit or Grout Inspection by Date inal Inspection by Date <br /> Additional Comments: a <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - , ❑ Tracy 83546385 <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 K RECEIVED BY DATE PERMIT NO. <br /> INFO C <br /> + EH1429CH 13-24 1REV.t/ssl �Q �� <br /> J i �I- <br />__ a <br />