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li <br /> II <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l <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 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. j <br /> City Lot Size PM <br /> Job Address <br /> SJa <br /> 1^7 ` q jC� Phone <br /> Owner's Name Address <br /> i3 { <br /> Address QoLicense No 2ZfQ Phone � � <br /> Contract <br /> TYPE OF WELL/PUMP: NEW WELL 11WELL REPLACEMENT L-1DESTRUCTIONLJ <br /> PUMP INSTALLATION ITSYSTEM 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 /> F7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy r � Type of Casing Specifications <br /> t Type of Grout <br /> 171 Public C1 Other ❑.Delta�'�""`-•""'�Depth-of-Grout Seal -`-- YP <br /> ❑ Irrigation LApprox. Depth ❑ Easternj Surface Seal Installed by <br /> Repair Work Done El Type of Pump W.P.F-�^- State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth �- -Filler Atenol-(Br`low 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION e REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> l �• <br /> Installation will serve: Residence Commercial_ Other ie'- ° E-r; <br /> _ r <br /> Number of living units: Number of 1drooms. <br /> Character of soil to a depth of 3 feet: Water table depth S <br /> SEPTIC TANK gKTYO,/Mfg Capacity —�,No. Compartments <br /> i PKG. TREATMENT PLT. 71 < <� Method of Disposal <br /> 1 <br /> 11 Distance to nearest: Well dU Foundation _;—,ProPBrtY Line_s <br /> li <br /> "'T <br /> LEACHING LINE No. & Length of lines otal length/size <br /> Pro <br /> FILTER BED 11 Distance to nearest: Well�DD f - Foundation party Line <br /> SEEPAGE PITS 17 Depth //1 Size _Number � <br /> Line <br /> Well Foundation <br /> 1 �� 7""�— Property <br /> I SUMPS W�Distance to nearest: —{�— <br /> E DISPOSAL PONDS ❑ <br /> .-.-.I..hereby-cartify-that-l-have-ptepared-this-applicafion-and-that-the-work-will-be-done-in-accordance-with-San-JGaquih county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> i g: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the followin <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 st call fo al equired inspections. Complete drawing on rave e. f <br /> Signed Title: Date: <br /> 1� <br /> !I FOR DEPARTMENT USE ONLY � <br /> s Area <br /> k ZI-oir <br /> ation Accepted by Date <br /> r t Inspection by Date Final Inspection by <br /> .,I <br /> Additional Comments- <br /> ❑ Stk 466-6781 ❑ 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 /> .i <br /> FEEAMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY HATE PERMIT'NO. <br /> INFO • <br /> +EH 13-24(REV.i/65) <br /> FEFI-i42a>,� <br />