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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 t <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> u (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: <br /> I' ve r City Lot Size PM <br /> Job Address J,�{�j�,/I {%� <br /> a Address ! 1 �O i ✓ei�U`y[ Phone�� I ^ D <br /> Owner's Name }g <br /> J1� r <br /> TMContractor "+� (if e r Address Q S I Vr'kdcense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK 100 SEWER LINES DISPOSAL FLD 1004 PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> 6 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Cas�g� <br /> 'p Industrial ❑ Open Bottom D Manteca Dia. of Well Exc vaTlo (�2 <br /> :DomesticlPrivate Gravel Pack ❑ Tracy Type of Casing // Specifications�p��,,,,JJ__,�`.��.��, <br /> 1-1 Public n Other F1 Delta Depth of Grout Seal Type of Grout7L1 <br /> I i Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by <br /> - _ <br /> Repair Work Done LJType of Pump H.P. State Work Done <br /> F <br /> Well Destruction ❑ Well Diameter Sealing Material itop 501 j <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR?ADDITION l I DESTRUCTION I i aNailabpticle systithinem <br /> permitted if public sewer is <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 r . <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED LI Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> ication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this appl <br /> rules and regulations of the San Joaquin Local Health D%i trict. <br /> I 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 /> 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 applica m .111 for pil required inspections. Complete drawing o averse side. <br /> Title: Date: <br /> Signed X <br /> F F R DEPAR MENT USE ONLY <br /> Area O� <br /> Application Accepted by f Date <br /> r Pit or Grout Inspection by Date A1Final Inspection by Date <br /> Additional Comments: <br /> r Q Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-71 ❑ 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 CK <br /> RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> i <br /> +.EH'53.24MEV.rik51 �(a ( <<O IR3c15 <br /> EH 14-26 <br />