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3 <br /> APPLICATION FOR 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 /> Vourity <br /> LTH (Complete in Triplicate) <br /> Application is @i `fti S�aquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in coni �iOrdinance No.549 for sewage or No. 1862 for well pump and the Rules and Regulations of the San Joaquin <br /> Local Health Disi to <br /> Job Address Ci s <br /> itt�y Lot�Siizze� Ply (� <br /> Owner's Name ess.14. -1-7i� �-+"� Phone � <br /> Contractor's Name License No. 3•�' Phone <br /> - TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT k❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION fe SYSTEM.REPAIR'❑ i OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> - FOUNDATION A- RICULTURE_ WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA a CONSTRUCTION$PECfFICAT[048— _-­ -.— ` ,� <br /> ❑ Industrial CJ Open Bottom ❑ Manteca Dia. of Well Excavation W <br /> Dia. of Well Casing <br /> ®'6omestic/Private ❑ Gravel Pack IJ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal v <br /> ❑ Irrigation A Type of Grout <br /> --Approx. De h ❑ Eastern Surface Seal Installed by , <br /> Repair Work Done [B' Type of Pump crs9r� H.P. / State Work Done .0 e O'L-& <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 r <br /> Depth Filler Material (Below 50') r i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION'❑ (No septic system permitted if public sewer is <br /> 1 i <br /> Installation available within 200 feet.) <br /> Number <br /> will serve; Residence_ Commercial_ Other <br /> Nu 6 <br /> Number of living units; Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK <br /> Water table depth <br /> ❑ Type/Mfg Capacity , No. Compartments <br /> PKG. TREATMENT PLT. ❑ �t Method of Disposal, <br /> Distance to nearest: Well Foundation Property Line <br /> J ' <br /> LEACHING LINE ❑ No. & Length of lines ' <br /> FILTER BED r� <br /> Total length/size <br /> .:_©—Distance,to-nearest:._,Well,-k Foundation -a =-Property Line <br /> SEEPAGE PITS ❑ Depth Size Number (� 1 <br /> SUMPS ❑ Distance to nearest: 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 �r <br /> rules and regulations of the San Joaquin Local Health District. e <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 1 <br /> employ any person in such manner as to become subject to workman's compensation laws of California.,, Contractors hiring or sub-contracting signature .4 <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 applicant c I for all re uired inspe ons. Complet drawing on reverse side. <br /> Signed <br /> r Date: <br /> F OR DEPARTM NT USE ONLY {'— <br /> Application Accepted by Date ��/��ifJ <br /> Area <br /> Pit or Grout Inspection byDate Final inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 3593621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 a <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 CK <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> +EH 13-24 EH W26{REV.10183E JIS ` Q� <br />