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APPLICATION FOR PERMIT <br /> 1� r SAN JOAQUI.N LOCAL HEALTH DISTRICT <br /> �l <br /> 1601 E. HAZE T ON AVE., STOCKTOIV, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> > d (Complete in Triplicate) <br /> Application is heieby 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 /> �f Cit <br /> Job Address Y Lot Size <br /> l <br /> Address PhonOwner's Name J <br /> I 72?d <br /> Contractor Address cense Noz Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia: of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack d Tracy -Type of Casing Specifications <br /> 1`1 Public n Other Ll Delta Depth of Grout Seat Type of Grout _ <br /> I I Irrigation _.-Approx. Depth l 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Belo i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 DESTRUCTION I 1 1No septic system permitted if public_ sewer is <br /> available within 200 feet) <br /> Installation will serve: Residence Commercial= Other <br /> Number of living units: Number of bedr oms . <br /> (Q'f i4 <br /> Character of soil to a depth of 3 feet: ;Water table depth yi <br /> SEPTIC TANK ❑ .Type/Mfg 7✓ f' Capacity t No. Compartments r <br /> PKG. TREATMENT PLT. ❑ atr '�, Method of JDsposal <br /> Distance to nearest: Well/0-0-4 Foundation Property Line <br /> LEACHING LINE ❑ No- & Length of tines Total length/size <br />,.. FILTER BED ❑ Distance to nearest: Wekl Foundation 4-Property Line i r <br /> SEEPAGE PITS r I I Depth Size Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will bedone 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 alk r it i ctions. Comp ete cawing on v se side. <br /> Signed X Title: � Date: <br /> FOR DEPARTMENT USE ONLYApplication Accepted by i J 4 Date Area <br /> Pit or Grout Inspection by Dgte Final inspection by D�attj <br /> Old L— <br /> Additional Comments: Q C/ C,cG1 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT'NO. �] <br /> +.EH 13-24 IR v/M51 d j ATEH 14-28 19 . 6 <br />