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_ ArPPL1r,AT10114 FOR PERMIT <br /> f` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 J <br /> Local Health District. <br /> ii. <br /> x � � City Lot Size PM <br /> Job <br /> b Address .., .. -- - -�s <br /> Owner's Name <br /> �� �/�/l Address Phone <br /> �,� <br /> License No. Phone <br /> Contractor T ` Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 1:1 <br /> _ OTHER ❑ <br /> PUMP.INSTALLATION L1SYSTEM REPAIR ❑ <br /> ' SEWER LINES <br /> DISPOSAL FLD.— PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK . <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> T <br /> . <br /> ,INTENDED USE— —TYPE OF WELL ri PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of 011, Casing <br /> 0 industrial ❑ Open Bottom-f 171Manteca Dia. of Well Excavation gpecifications <br /> 11 Domestic/Private ❑ Gravel Pack € I ❑ Tracy Type of Casing <br /> Type of Grout <br /> 1'1 public �-- -lel Other - El Delta Depth at Grout Seal ,. <br /> I I#Itrigafion M_ --..Approx. Depth I I Eastern Surface Seal Installed by ; <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction .F ❑, '-Well'Diameter, Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I 1 iNo septic system pefmi7, ,cis <br /> available within 200 feet. <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:;; J � Number of bedrooms Character of•soil to a dep of 3 feet: Water table depthY <br /> SEPTIC TANKType/Mfg '9 Capacity? 1 — No. Compartments <br /> PKG. TREATMENT PLT. Method ofr7DispTaal <br /> CI <br /> Distance to'nearest: Well Foundations` �� Property Line <br /> LEACHING LINE No. & Length of lines Total length/size <br /> FILTER HED v ❑ Distance to nearest: Well 3 Foundation,J� Property Line,=.!N21 <br /> 1 SEEPAGE PITS l l Depth Size Number <br /> SUMPS I Ll Distance to nearest: Well Foundation Property Line <br /> 1 DISPOSAL PONDS ❑ <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and_regulations"of the San Joaquin Local Health District. <br /> Home owner or ticensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring of sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California <br /> The applicant mus c I for all required ins. ns.C lets drawing on reverse side. <br /> Si ned X ti Title: Date: <br /> g <br /> ����11��USE LY _ --- – - <br /> fF ? Date ``� �� Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final inspection by <br /> �1 3 Date <br /> -.Additional-Comments:' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> p FEE AMOUNT DUE AMOUNT REMITTED 'CK RECEIVED BY DATE PERMIT ND. <br /> INFO <br /> + EH 13-24(REV.1/n 5) <br /> EH 14-26 <br />