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iT <br /> x APPLICATION.FOR PERMIT <br /> SAN JOAO.UIN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON.AVE., STOCKTON, CA <br /> a Telephone`(209) 466-6781 k. <br /> PERMIT EXPIRES 1.YEAR FROM DATE ISSUED <br /> ` - w (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 /> fw 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, sa <br /> C.d <br /> Job Address CityLot Size %__5 PM <br /> Of <br /> Owner's Name n "� dress Phone <br /> f <br /> I Contractors Address L A� License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST-SEPTIC TANK SEWER LINES DISPOSAL FLD.'l PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ? PITS/SUMPS. <br /> INTENDED USE TYPE-OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS.4 <br /> i <br /> ❑ Industrial O Open Bottom`s'"`'""❑ Manteca Dia. of.Well Excavation ' Dia. of'1Nell Casing <br /> ❑ Domestic/Private LJ Gravel Pack ` ❑ Tracy Type of,Casing Specifications, <br /> ❑ Public ❑ Other f ❑ Delta Depth of Grout Seal r'" I Type of Grout <br /> ❑ Irrigation <br /> ---Approx.: Depth ❑.Eastern Surface Seal Installed-by <br /> Repair Work Done.. ❑ Type of Pump H.P. f State Work Doneij <br /> Well Destruction ElWell Diameter Sealing Material (top 501) x1 f t) ! <br /> Depth # Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑, DESTRUCTION ❑ (No septic system permitted if public sewer is d <br /> available within 200 feet.) <br /> Installation will serve: Residence' Commercial� Other <br /> i _ s <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet Water r table depth d J# ' <br /> SEPTIC'TANK 8 Type/Mfg Capacity__/ZQ d__ ' =No. Compartments <br /> PKG. TREATMENT ALT. Q "Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE No. � Length of lines D i <br /> �' 9 Total length/size a <br /> FILTER BED ❑ Distance to nearest: Well r <br /> �� Property'Line�@� i <br /> s Foundation <br /> SEEPAGE PITS ❑ Depth Size } Number i <br /> SUMPS Distance to nearest: Well 40�t Foundation ��a'_ Property Line < <br /> DISPOSAL PONDS ❑ 1 p # } <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 i <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,'l shall employ persons subject to workman's compensa- <br /> tion laws of California." ti, 1 <br /> The applicant must call for all required inspect' s. Complete drawingran reverse side. <br /> .a.�. ...^wy. <br /> Signed Title: Date: `..ZY" d` <br /> FOR DEPARTMENT USE ONLY i. } <br /> Application Accepted by Date 1, 3 7/ Ares 46 -7 <br /> ��Pit or Grout Inspection bj "" Date Final Inspection by Date 1!2� <br /> Additional Comments: r - Grp 6/Yr i dr <br /> © Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Q Tracy 83546385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 i <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> =-r <br /> +.EH13-21fREV.siesl —76 ,.QQ %� <br /> EH 1428 <br />