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} <br /> A <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ' <br /> too Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUtD ' <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install.ihe 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 /> 4 . <br /> Job Address City�_ Lot_Size-5b („/60 PM <br /> CC,�''�� _ C-7 ,. <br /> Owner's Name!! t Address '” w•" '�66 <br />� .,._ Phone <br /> Contractor -Address t .a�--.� _License i MI—la—Phone '1?60 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ SWELL REPLACEMENT D DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTfM REPAIR ❑ - I OTHER ❑- Y <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES , -DISPOSAL FLD. PROP. LINE <br /> t FOUNDATIONAGRICULTURE WELL - OTHER.WEL'L_G PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA-4CONSTRUCTION-SPECIFICATIONS <br /> ❑ Industrial -4.❑ Open Bottom ❑ Manteca w - Dia.,of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack '` %_❑ Tracy ="`�`` Type of Casing Specifications <br /> F Public * tt-n Other.- c ' -FI-Delta Depth of_Grout.Seal Type of Grout <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work pane ❑ Type of Pump <br /> H.P, State Work Done _ �- <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION DESTRUCTION i I (No septic system permitted if public sewer is <br /> !,,available within 200 feet.) <br /> Installation will serve: Residence Commercial Other I <br /> Number of living units: / Number of bedroom / <br /> t 1 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> ,SEPTIC TANK X Type/Mfg t C acity No. Compartments 2� <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑' Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size { % _ Number j <br /> SUMPS Ll Distance-to.nearest:.-. ,Well ----`..'- Foundation _P.roperty_Line-. <br /> DISPOSAL PONDS ❑ <br /> 1 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 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 mus • all for r uired s cti s�Complete drawing on ver side. <br /> CILZ&Signed X � Title: � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 1-3_000 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ n ; <br /> ❑ Stk 466-6781 ❑ Lodi 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 /> � I <br /> FEE CK <br /> INFO ^/A�JjMJOU6NT DUE AMOUNT REMITTED C H RECEIVED BY DATE PEkMIT-NO. <br /> +,EH 14'241REV,1ix51 <br /> EH 14-2a /U <br />