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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601h E. HAZEL i OiV AVE., STOCKTON, CA <br /> \ Telephone-(209) 466-6781 <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 work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No.549 fnr sewage or No. 1$62 for well/pump and the Rules and Regulations o1 the San Joaquin <br /> Local Health District. <br /> Job Address <br /> City Lot Size &C64 PM <br /> � 1 ^� <br /> Address �Q tr' H9ei h / Phonea3 i <br /> Owner's Name ' <br /> ' v� License No.vPhone <br /> 2 ` l- 3 _!SJ 7?? <br /> Contractor Q �� Address �'�, <br /> TYPE OF?WELL/PUMP: , WELD':. WI=LL REPLACEMENT _ DESTRUCTION F <br /> IAl of <br /> PUMP•INSTAL-LATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK'+�.SO. SEWER LINES .., .1 POSAL`FLD.3 f PROP. LINE �� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i` INTENDED USE," -,TYPE OF WELL-, PROBLEM AREA CONSTRUCTION SPECIFICATIONSI r r <br /> .�.. Dia. of Well Casing <br /> 0 Industrial Open Bottom <br /> LJ Manteca Dia. of Well Excavation 9 <br /> ' pomesticlPrivate O Gravel Pack ❑ Tracy Type of Casing ��._.� Specifications .� <br /> 1`1 Public± • FI Other r F] Delta Depth of Grout Seal' Type of rout) G w� <br /> I I Irrigation 0 Approx. Dept t,lf_l_Eastern Surface Seal Installed by e! - <br /> Repair Wrk Done CI Type of Pump i, H.P. _ I State Work Done <br /> o <br /> Well Destruction )t_�.Welhl Diameter ._ Sealing Material (top 501""'"" - = e, <br /> _ Dep h 15 — Filler Material 18elow 501 �>d_l.!- <br /> TYPE OF:SEPTIC WORK: NE=INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION I 1 {No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve:-Residence_ Commercial— Other— <br /> Number <br /> ther Number of living units: f " Number of bedrooms <br />` ° • 1 <br /> Character of soil to a depth iof 3 feet: Water table depth <br /> SEPTIC TANK ❑ ;Type/Mfg Capacity No. Compartments <br /> PKG.,TREATMENT PLT. ❑ i Method o1 Disposal <br /> -`Distance to nearest:—Well — -•FoundAtion--�••Property-Line—r= <br /> - <br /> LEACHING LINE Cl ,�No. & Length of lines Total leri9th/size <br /> FILTER BED ❑ iDistance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I ':Depth Size Number <br /> r <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 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 /> w w tion laws of California." <br /> t <br /> The applicant nAust call for ail requir d inspections. Complete drawing on reverse side <br /> Signe Title:. Date: } <br /> w+ FOR DEPARTMENT USE ONLY <br /> t Application Accepted by Date Area <br /> !'. /�- Date - <br /> Pit or Grout Inspection bwp Date / Final Inspection by <br /> Additional Comments: ` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8234104 sy ❑ Tracy 835-6385 r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE' PERMIT NO. <br /> INFO <br /> ` . <br /> ♦ EH13-24{REV.r/H 51 <br /> EH 14-2e - Ill-..11Y�� <br /> i1 el <br /> f <br />