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i <br /> ; „/ APPLICATION.FOR PERMIT <br /> P 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 /> j yI (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 /> i Job Addres O Q City Lot Size PM. <br /> Owner's Na Address 443 All l�4Da�� <br /> Contractor Address License No. Phone <br /> TYP ELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 3 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST—SER—TIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDA AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia—761- II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 13 Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout a <br /> ❑ Irrigation + —.Approx. Depth ❑ 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') <br /> Depth Filler Material (Below 501 <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_... Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> I <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I' Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> T FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well v ` ; F undation A Property Line <br /> DISPOSAL PONDS ❑ <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 4 <br /> employ any person iwsuch 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." -s <br /> The applicant must call foh all required inspections. Complete'drawing on'reverse side. (� <br /> r Signe d iTitle: !(9!1 AM(,.fl Date: P7 I <br /> .. <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedby Date �r Area <br /> - <br /> I Pit or Grout inspection by `Date `"Final.lnspection by Dat <br /> ` Additional Comments: I ' <br /> Ii ❑ Stk 466-6761 ❑ 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 /> u <br /> I �r <br /> FEE AMOUNT DUEAMOUNT REMITTED CK RECEIVED By DATE gPEIY'NO.INFOL �+_ <br /> EH 1428 % <br /> EH 13-24 fREV.tiH51 - 5S f-" /D - <br />