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a � 1, <br /> APPLICATION FOR PERMIT <br /> .� 4.USAN JOAQUtN LOCAL HEALTH DISTRICT � <br /> w ' 1601 E. HAZEL II WAVE.'. STOCKTON, CA <br /> ��. Telephone {209}' 466-6781 <br /> A. <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%, r;V her'�pta scribed. Thi§�a ation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and egulatigr s of Joaquin <br /> Local Health District. <br /> Job AddAName -6 <br /> Cit Lot Size PM <br /> Owner's Address �Q n if f C G Phone 2.Contract dress +� <br /> License No. 3 Phone <br /> TYPE OF WELL/PUMP<, NE WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i I PUMP INSTALLATION ❑ SYSTEM REPAIR er-- OTHER ❑ <br /> DISTANCE TO:NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> } eL FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE. - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> —0 Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Q bomestic/P,rivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> i-i Public Cl Other C 1 Delta Depth of Grout Seal T e of Grout <br /> I I Irrigation / _Approx. Depths hl.EEaastern Surface Seal Installed by <br /> Repair,'Work Done CB' Type of Pump _..v��- _ H.P. f - State Work Done <br /> Ce <br /> Well Destruction.".—❑--' Well'Diameter- f(—Sealing['Material [top 50') <br /> i Depth e. "jFiller Material (Below 501 <br /> TYPE'OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADOIT++ION I I DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial l _O'Iher `� t i t <br /> Number of living units: Number of bedrooms 1- 4 v I - <br /> Character ofisoil to a depth of 3 feet: k I �f-�` j� Water table depth <br /> SEPTIC TANK( U Type/Mfg i \i t \ i Capacity No. Compartments <br /> PKG.IT <br /> PLT. ❑ aR' Method of Disposal <br /> - �. _= --- <br /> Distance to nearest: Well Foundation- Property Line <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> 0 1 <br /> FILTER BED t ❑ Distance to nearest: Well Foundation Property Line <br /> s i <br /> 4 i <br /> SEEPAGE PITS; I'1 Depth Size Number <br /> I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑. <br /> I hereby certify ithat a repared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules!and re ions of the Joaquin Local Health District. <br /> Home ow r or,licensed agent's ignature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> em'loy. y person in such mann r as to be o e subje workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies he followi • '9 certify t in th a of he work for which t is permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law of Cal" or ' 1. <br /> The appli nt mu r equire plot drawing on ev ' Allolaw�x <br /> Signed Title: ate: <br /> VIrDEPARTMENT USE ONLY <br /> Application Accepted by Date Area ' <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.O. Box 2009, Stk., CA 95201 <br /> 1FEE E0 AMOUNT DUE AMOUNT REMITTED CK 49 CASH RECEIVED BY HATE PERMIT'NO. <br /> a.EH 13.24MEV.rin51 V: <br /> EH 14-28 C=�c? <br />