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uAPPLICATION FOR PERMIT <br /> oSAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> I Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> k (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 /> f /��1�,y <br /> i Job Address ��• Cit u"''Ldttlo Size PM <br />€ C t �f y'-- 4 <br />€ Owner's Nam Address J �'� <br /> Phone <br /> Contractor Address CA;— ��OLifnse No. �— Phone-X-X �`�"$�Ic <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 /> s )Cbomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public D Other LJ Delta Depth of Grout Seal Type of Grout­—­ <br /> I <br /> rout_—. _ <br /> `r g' --Approx. Depth { I Eastern Surface Seal y <br /> l Installed b <br /> I I Irrigation A _ <br /> Repair Work Done ❑ Type of PumpH.P. State Work Done <br /> - W2 0-11910 <br /> Well Destruction ❑ Well Diameter Sealing Material {top 5011 M <br />} Depth Filler Material (Below 50'I _ Q .14 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:] REPAIR/ADDITION I I DESTRUCTION I i (No septic system permitted if public sewer is <br /> available within 200 feet.) [L, <br /> Installation will serve: Residence'_w Commercial_ Other "�\J <br /> Number of living units: Number of bedrooms r - <br /> Character of soil to a depth of 3 feet: ' .r Water table d <br /> SEPTIC TAMC ❑ Type/Mfg + t Capacity No. Coil <br /> r <br /> PKG. TREATMENT PLT. fl <br /> Me . o rsposal <br /> Distance to nearest: Well Foundation Property-Line <br /> 1989 <br /> LEACHING LINE ❑ No. & Length of lines I �Total-iength/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation b" Property LiTWPOTAL HEALTH <br /> J. ; <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 Di-strict. ! <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'F <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 mut ill for all re i d inspections--Complete drawing on verse side. <br /> Signed X } '� `7 ' Title: .Z i <br /> Date: { <br /> FOR DEPARTMENT USE ONLY R ;€ <br /> Application Accepted by w / �� <br /> T Date - Area <br /> Pit or Grout Inspection by - Data Final Inspection by Date ` <br /> Additional Comments: <br /> ❑ Stk. .466-6781-., ` '(] Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant--Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. <br /> INFO CASH <br /> +.EH 13-24[REV.t i n 5) <br /> EH 14-2e ✓C a y l Y�`O 1 x-17 a yi <br /> P <br />