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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. <br /> iA i <br /> Job Address City - Lot Size PM <br /> Owner's Nhfrfe;� + -AddressPhone - - - <br /> h <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t , , PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ R +� OTHER ❑ rt <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL-ELD.-- `:PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE_ 1 TYPE OF WELL PROBLEM AREAT 'CONSTRUCTION SPECIFICATIONS <br /> 1-7Industrial El open Boftoin*' D Manteca Dia. of Weli Excavation '"b .-of Well Casing <br /> ❑ Domestic/Private Ll Gravel Pack El Tracy m Tywof•Casing Specifications <br />'. ❑ Public ❑ Other =. ❑ Delta " De Depth of Grout Seal <br /> P Type of Grout i <br /> El �4pprox. Depth ❑ Eastern. Surface Seal Installed by <br /> r Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 \ <br /> k <br /> Depth Filler Material (Below 50 V, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will serve: Residence Iff"� Commercial— Other <br /> Number of living units:—1— Number of bedrooms <br /> Character of soil to a depth of 3 feet: ' Water table depth <br /> SEPTIC TANK - ❑ Type/Mfg Capacity (20 No. Compartments <br /> PKG. TREATMENT PLT: ❑ Method of Disposal j <br /> Distance to nearest: Well 4_bt) Foundation.�r� Property Line (l <br /> LEACHING LINE No-2& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well�_(�6 Foundation Z'7 1) Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well LIQ, Foundation J--illOProperty.Line 1 <br /> 4 DISPOSAL PONDS— Cl­ <br /> 4F JW'61— <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 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 /> The applicant must call for all require pections. Comp to drawing on rev mq side. r <br /> Signed Title: Date: 9';: � <br /> FOR DEPART ENT USE ONLY <br /> A 'cation Accepted by ' Date 7 �� � ea <br /> 3 <br /> Pit or Grout Inspection by 1P Final Inspection y to <br /> &_Ad tional Comments: <br /> i' 77/44 IA <br /> k 466 6781 ❑ Lodi 369 36'11 Manteca 823-7104 ❑ Tracy 8355-6365 <br /> S { Appli ant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i f <br /> FEE <br /> fNFO AMOUNT�DU f2 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"N0. <br /> + EH 1&24(REV.101831 I <br /> j EH 1428 �i - <br /> r <br />