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s <br /> .__ " APPLICATION FOR PERMITS <br /> T� <br /> ii SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r r^0 <br /> 4- 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete in Triplicate? 1 ]� <br /> -Application is hereby trade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application'f y <br /> made in compliance with San Joaquin County.Ordinance No. 549 for sewage or No. 16432 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District: <br /> Job Address f 4City Lot Size ZPrvI <br /> Owner's Name n Address J -56 —y Phone <br /> Contractor "'✓ ? `� Address License No. Phone <br /> TYPE OF WELL/PUMP: wi NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES �Zfi DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG ULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS ~ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> 4 <br /> ❑ Domestic/Private -❑ Gravel Pack ❑ Trac -Typ off Casing Specifications <br /> 171 Public ❑ Other Cl to Depth o-Grout Seal Type of Grout y <br /> I I Irrigation -Approx. Depth I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done T <br /> Well Destruction ❑ Well Diameter Sealing Material itop 50'1 <br /> Depth. Filler Material !Below 501 <br /> TYPE OF SEPTIC WORK: NEW itNSTALLATION I 1 REPAIR/ADDITION l 1 DESTRUCTIOWlailable <br /> o septic system permitted if public sewer is I 1 <br /> within 200 feet.) <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 N <br /> Distance to nearest: Well Foundation Property Line C <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L1 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, ander <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 notes. <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 applicant must call for all irequired inspections. Complete drawing on reverse side. <br /> igned XG� 2 Title: Date: <br /> ,In hOR ARTMENT USE ONLY <br /> Application Accepted by . KAO C4 "A /-cam Data Area <br /> Pit or Erlom' <br /> ut Inspectiorl.kl Date . Final Inspection by J Date 4 <br /> Additiments <br /> ❑ Stk 466-6781 ❑ Lodi 369-3 1 ❑ Ma tete 823-71 ❑ Tre y 6385 f <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelt Ave , P.O. Pox 2009, Stk.., CA 95201 f/Uv �r vVu/­r P <br /> FEE AMOUNT DUE AMOUNT REMITTED RE <br /> INFO CAS <br /> a EH 13-241REV.1/85) 2� 00 00 tC� <br /> l EH 14-M ` .1 <br />