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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Iy1 TSL HEALTH <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 /> 1u <br /> made in compliance with San Joaquin County Ordinance No,549 for sewage or No. 1B62 for welUpumP and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> RAJob Address City&,fdanj rAe&-- Lot Size PM <br /> Owner's Name Address d Phone 62S-&,1!,7 <br /> Contractor —� Address License No.4_/&�S120 Phone 20_� <br /> hw? <br /> TYPE OF WELL/PUMP: NEW WELL EI WELL REPLACEMENT LJ DESTRUCTION 0 <br /> PUMP INSTALLATION 0 SYSTEM REPAIR 1-1 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL — OTHER WELL— <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial D Open Bottom 0 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> VDomestic/Private El Gravel Pack CI Tracy Type of Casing— Specifications <br /> I'] public Fl Other F1 Delta Depth of Grout Seal r Type of Grout--.-- <br /> Surface Seal Installed by <br /> I I Irrigation _Approx. Depth 11 Eastern <br /> Repair Work Done Type of Pump H.P. State Wo k Done <br /> Well Destruction 1-1 Well Diameter Sealing Material (top bU <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION.1.1 REPAIR/ADDITION ( I DESTRUCTION [,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 bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK [I Type/Mfg Capacity— No. Compartments <br /> PKG, TREATMENT PLT. FI Method of Disposal <br /> 77 <br /> Distance to nearest: Well Foundation 'Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well— Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L-1_6i.Distance to-nearest:: —: Well- -Foundation Property.Line, <br /> .2. <br /> DISPOS CPGNDS <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 comppnsati6n 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 <br /> ompensa-tion laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> Tit 041t�l <br /> Signed X le: Date: -7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> D te <br /> Pit or Grout inspection by Date .Final Inspecti.n:bX,.;,1 <br /> Additional Comments: <br /> 0 Sik 466-6781 0 Lodi 369.3621 0 Manteca 823-7104 0 Tracy 835-1015 <br /> Applicant - Return 611 copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH 13-24(REV.1 5) 9fto�qo qo—.XLI <br /> EH 14-26 <br />