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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 C my Ordinance No.549 for sewage-or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. tjl 2 <br /> Job Addres / City Lot Size _ -� PM <br /> I Owner's Name - Address Phone <br /> Zk4lLicense No. ?� / fContractors Address . `�' <br /> TYPE OF WELL/PUMP: NEW WELL ElWELL REPLACEMENT ❑ DESTRUCTION LJ <br /> PUMP INSTALLATION ElSYSTEM 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 /> ^' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation k- Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing I Specifications <br /> M1 ['l Public Fl Other f7 Delta Depth of Grout Seal k Typebf Grout - <br /> ws 1 1 Irrigation Approx. Depth l I Eastern Surface Seal Installed by— <br /> Repair <br /> y Repair Work Done [3 Type of Pump H.P. State Work Done 9 <br /> _Well Destruction ❑ Well Diameter Sealing Material (top•50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: rNEW INSTALLATION l 1 REPAIR/ADDITION k< DESTRUCTION I i (No septic system permitted if public sewer is <br /> " available within 200 feet.I <br /> 1 ' Installation will serve: Residence Commercial Other ` <br /> Number of living units: 4-- Numbeo� <br /> r of bedr •rls ` <br /> Character of soil to a depth of 3'feet: u - Water table depth <br /> No. Compartments Z^' <br /> w , SEPTIC TANK @?_,Type/Mfg X Capacity <br /> PKG. TREATMENT PLT. ❑ I Method Disposal <br /> t <br /> Distance to nearest: Well-4 0 Foundation 010 Property Line <br /> a r� <br /> LEACHING LINE 13-"No. & Length of lines . Total <br /> rotal length/size <br /> C FILTER BED ❑ Distance to nearest: rWell 'O f Foundation� Property Line <br /> k y <br /> SEEPAGE PITS ILI-1 Depth Sie O Number r <br /> ` SUMPS Ll Distance to nearest-. We(� '�— Foundation 1 Property Lined l <br /> DISPOSAL PONDS ❑ - <br /> hereby certify that t have prepared this application and that the work will be done In accordance with San JoagtiincoLnty ordinances,state lawsr;and <br /> rules and regulations of the San iJoaquin LoFal"Ffealth District'. --�-1- 1 1 '' 1 21- „. <br /> Home owner or licensed agent's signature c4rtifies the following: "I certify,thfj in the performance of the work for w ich this permit-isissued, I shall not <br /> employ any person in such manner as.to beoerna-Wh,i t to we—' <br /> kmn'scompensation laws of;,Califo{nia."Contractor's;hi I{ng or sub-contracting signature <br /> certifies the following: "I certify that in the performance ontTe wh•t` <br /> ork far whicwis permit is issued!k shall employ persons subject to workman's compensa- <br /> tion laws of-California." �„ �•.A �+i r�^•� ' <br /> r :3 <br /> The applica .must call for al required inspections.,Cb'-ra�pl-emote^'d ing.on..reversa.side.; _-` <br /> Signed ~ ". 1 T tle:_410 M �_ Date: 0 3 <br /> FOR DEPARTMENT USE ONLY <br /> sW <br /> 2— <br /> Application <br /> Application Accepted-Dy <br /> Date ` r Area <br /> it r Grout Inspection by 'CL <br /> � Final Inspection by Dat <br /> { <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935$385 <br /> Applicant - Return all copies to: Environmental Health Permit/Service ces 1601 E. Hazelton Ave., P.O. Box 2009, St k., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATlE PERMITIV <br /> " O. <br /> INFO ; <br /> ♦.EH 13-24(REV.1/"5) <br /> EH 14-28 ' <br />