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- APPLICATION FOR PERMIT <br /> A. 'r;;% a<-t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> + a x _.4-5 <br /> 1601 E. HAZELTONAVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-1-1YEAR FROWDATE ISSUED" <br /> (Complete'ii Triplicate) ` , ' T <br /> r i vi -,.., �. - is - �, . <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 Ryles and Regulations of the San Joaquin <br /> 5'r it F.� ,i L.Yui'• i.-., :f: <br /> Local Health District. ►:^V . r w. <br /> Job Address <br /> t'Si�VI v�:3 ':( j ♦� _��0.irt �'j�4`.}G.i _. ..� :s. x -� '� .. <br /> Owner's Name' - ' Address - - Phone <br /> Contractor Addfessl License 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. - PROP. LINE <br /> FOUNDATION AGRICULTURE WELL .OTHER WELL PITSLSUMPS.. <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 ❑ Gravel Pack ❑ Tracy, 'Type of Casing Specifications <br /> ❑ 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 <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 50'1 <br /> Depth x Filler Material(Below 50'.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is N <br /> - available within 200 feet./ <br /> Fr. <br /> Installation 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 ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal ` <br /> Distance to nearest: ,,Well Foundation Property Line <br /> y <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> G <br /> FILTER BED ❑ .Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth + Size Number <br /> SUMPS ❑, Distance to nearest: Well Foundation z,Property_Line <br /> DISPOSAL PONDS - ❑- �. g - * �„ Y R` f r— T ..s.- <br /> - t <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 /> i 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." Contractor's hiring or sub-contracting signature i <br /> I 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 taws of California." <br /> The applicant ust call all required inspections. Complete drawing on r rse side. <br /> A, <br /> Signed J — Title: `y Date: ; —.. <br /> FOR DEPARTM T USE ONLY <br /> Application Accepted by - Date <br /> 4 Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 yr' .; <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,Stk., CA,95201 <br /> FEE AMOUNT bUE-_ AMOUNT REMITTED CA H RECEIVED BY ., DATE PERMIT'NO. <br /> 1' INFO <br /> 4 +.EH13.241REv.]La513s•ao - y i <br /> EH 14-26 S • 4 O ':51 ~lg(p �j�p-^� <br />