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r ~ <br /> .> APPLICATION FOR PERMIT <br /> a' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> k 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. I r <br /> f <br /> � I <br /> Job Address City Size ply <br /> I r <br /> I Owner's Na // <br /> Addres Phoner� tO <br /> a or <br /> ����ic�ense No.,/ <br /> t'O Phone <br /> TYPE OF WELL/PUMP: NEW'WE III WELL REPLACE ENT ❑ DESTRUCTION ❑ <br />' PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ r <br /> DISTANCE TO NEAREST: SEPTIC TANyK SEWER LINES DISPOSAL FLD. PROP. INE'k11 <br /> FOUNDATION I AGRICULTURE WELL OTHER WELL j aR TI S/SUMPS1 "~ <br /> INTENDED USE TYPE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D Industrial ❑-QpeniBoftoin{ �C�-Manteca---.,. Dia—of-Well-Excavation- _Dia,-of_Well-Cas ng._ <br /> omestic/Private ❑ Gravel Pack ❑ Trac Type ype of Casing Specificat�s� I <br /> M Public C] Other ❑ Delta Depth of Grout Seal T e of Gr t ti <br /> € I Irrigation Approz.' Ih ] El tern Surface Sea! Installed by YP � <br /> Repair Work Done ❑ Type of P p H.P._! State Work Don - <br /> WeII Destruction Q Well Diameter / 'a'A <br /> ti �, Sealing Material (top 50') <br /> x3 13` ( ,� � De tlkSg tet✓ \ I <br /> P Filler Material (Below 50') <br /> TYPE OF'SEPTIC WORK;yNEW INSTILLATION 1.1 REPAIR/ADDITION I i DESTRUCTION I I IND septic system permitted it(publi sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence 714 <br /> CommercialI <br /> _ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK, ❑ Type/Mfg i Capacity No, Compartments <br /> PKG. TREATMEN7`P1LT. ❑ Method of Disposal <br /> Distance to nearest: Mall Foundation' Property Line <br /> j <br /> i LEACHING LINE ❑ No. & Length of lines <br /> Tota! length/size <br /> FILTER BED ❑ Distance toynearest: i Well Foundation Property Line <br /> SEEPAGE PITS I i Depth Size _ Number <br /> SUMPS ❑ Distance to neatest: Well Foundation Property Line <br /> ^ ,DISPOSAL_PONDS _ O____ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, <br /> `an and <br /> rules and regulations-of the-5Jo'aq'tiin-Local- Healt#r�Di§trict--� _ <br /> Home owner or licensed agent's signature certifies the following : "f 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 /> � f <br /> The applicant must qVill foa!I required inspections. Co`pfete drawing on re rse a. <br /> 1 <br /> Sign <br /> Title- Date: <br /> f <br /> y <br /> �2. P06EPARTPIAIENT USE ON <br /> Application Accepted by - Date Area "Z/ <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Data r f a <br /> # f <br /> Additional Comments: fl <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 1:7 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 <br /> INFO GASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH1211AEV.iirs5l ��L q0_ l��! <br /> EH 1414-20t1 f `[O <br /> , <br />