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APPLICATION LIFOR PERMIT <br /> 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 /> (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. A .. <br /> O A&LOPE orf i' <br /> Job AddressCity ot Size PM <br /> Owner's Name Jr,��c£�� Address " Phone 3 ! <br /> Contractor's Name ✓ '� License No. 1 Phone ". <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. F PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing •� <br /> ❑ Domestic/Private t.. ❑ Gravely Pack' ❑ Tracy -Type of Casing Specifications <br /> 4� µ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by + [\ <br /> Repair Work Done. ❑ Type of Pump H.P. State Work Done ' O <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50') j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION V REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_X Commercial_ Other t <br /> Number of living units:L Number of bedrooms <br /> Character of soil to a depth of 3 feet: i Water table depth �C <br /> SEPTIC TANK j4a' Type/Mfg " ' 6apicity-Agi; r, Naf. Compartments <br /> PKG. TREATMENT PLT. ❑ s ` f f Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ' ti <br /> LEACHING LINE No. & Length of lines Total length/size l <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> t i <br /> SEEPAGE PITS Depth OT 4'` Size_ t Number <br /> t <br /> SUMPS ❑ Distance to nearest: Well 1 Foundation r f'& f Property Line <br /> .DISPOSAL PONDS ❑ ]f 1 J <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. i f - <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/`f <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 /> a certifies the following:"I certify that in the performance of the work for which this <br /> permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." 'f <br /> Y . � � i /4-. <br /> The applicant m ca or all required inspectiphs. Complete drawing on reverse side. <br /> f SignedX <br /> 1. I. Title:_— f <br /> s p Date: <br /> DEPARTM ONLY _ <br /> t Application Accepted by r '- - Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ~� <br /> Aggitional Comments: .1 14V <br /> PLStk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83544 —y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE r <br /> Pte... INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT"NO..e � <br /> +EH 1324Ir1EV.10!834 4, <br /> EH 1428 \7�' <br />