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44 APPLICATION FOR PERMIT „ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <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.10 <br /> t <br /> Iii <br /> Job Address f City e� Lot SizeUp_� m PM � <br /> Owner's Names,_��T�* Addressr <br /> Phone <br /> 1 I <br /> Contracto Address — License N, _F_-&3Phone <br /> TYPE OF WELL/PUW., NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom Q Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Public ❑ Other F1 ea Depth of Grout Seal Type of Grout <br /> I i Irrigation _._Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filier Material (Below-501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDiTION 1.1 DESTRUCTION (No septic system permitted it public sewer is p <br /> available within 200 feet.) <br /> 'Installation will serve: yResidence I'Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg: Capacity No.'Compartments w <br /> PKG. TREATMENT PLT.Q4 Method of Disposal <br /> e ° <br /> Distance to nearest: Well Foundation Property Line I. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED D Distance toinearest: Well Foundation Property Line f <br /> SEEPAGE PITS f I Depth I Size Number <br /> SUMPS L1 Distance toynearest: 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. i; <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 applican t ca f art require 'ns c 'ons. Complete drawing on rev rse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> !f <br /> Application Accepted by Date�L,_�_ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date —1` 49 _ <br /> Additional Comments: <br /> © Stk 466-6781 ❑ Lodi 369-36211 © Manteca 623-7104 ❑ Tracy- 635-6385 <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 RECEIVED 8Y DATE >7ERMIT N0. <br /> INFO ' <br /> N <br /> r EN 3-24(REV.t/Hsl _ <br /> EH 11-28 ��- 17—f—R7 4V_ <br /> q� <br />