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4 <br /> 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 TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �`lj <br /> Application is heceb made to the San Joaquin Local Health District fora permit to construct andlor install the work herein described. This application is <br /> App Y q <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1$62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. JQII�I <br /> — x: 0� � 2r3 � PM <br /> . _ y C City Lot Size <br /> G.- yy <br /> JabAddress� � t � � <br /> l3Larf <br /> Address11 <br /> Owner's ' Phone <br /> Owner's Name �s prr�- (� <br /> _ ✓fh��!r et Phone �® <br /> Contractor <br /> � Address FLicense No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �� 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ffv+P <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LIN �( <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ` {�C AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel[ Excavation Dia. of Well Casing <br /> Specifications <br /> C7 Domestic lPrivate ❑ Gravel Pack 401,1011acy Type of Casing <br /> M Public ❑ Other F1 Delta 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 1W, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION t 1 allo septilable c thin system permitted if public sewer is <br /> tnstallation will serve: Residence_ 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 YP 9 <br /> ❑ T e/Mf Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> Q. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I l 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. <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."Contractors hiring or sub contracting signature <br /> i <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,i shall employ persons suhiect to workman's compensa- <br /> tion laws of California." <br /> I{ The applica ust call for al a ired inspections. Complete drawing on r erso side. _ <br /> Signed X Title: <br /> ��/j( Date: <br /> F EP ENT USE ONLY <br /> Application Accepted by Date r <br /> I � <br /> Pit or Grout Inspection by Date Final Inspection Dat; <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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ;DATE PERMIT NO. <br /> INFO <br /> ..EH 13241REV.1/M51 .gyp <br /> EH 14-20 <br /> I <br />