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f , <br /> ( a 41P <br /> APPLICATION FOR PERMIT -r,4 raf 4f'� <br /> f <br /> + SAN JOAQUIN LOCAL HEALTH DISTRICT �aa <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> " 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 j <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. s <br /> i <br /> Job Address City Lot Size <br /> Owner's Name Address <br /> Phone <br /> Contractor <br /> Z /1,�' M Address ,blle� License No.�6.�/`a� Phone <br /> TYPE OF WELL/PUMP: NEW WELL $7 WELL REPLACEMENT F1 DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK 4141-4"e SEWER LINES DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL /s l PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia, of Well Casing lag " <br /> Ilomestic%Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications `*W4_ <br /> Public ❑ Other (-]'Delta--Depth of-Grout Seal-=�� Type of Grout _ �T <br /> iL-1rrigation _-Approx. De tf�h l l Eastern Surface Seal Installed by 15za 44 No <br /> epair Work Done Type of Pump amu/! H.P. g19 —State Work Done_ <br /> Weli Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:7 REPAIR/ADDITION I i DESTRUCTION E I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence_ CommercialeOther_. L { <br /> Number of living units: Number of bedrooms * CQ <br /> Character of soil to a depth of 3 feet: Water table depth' <br /> SEPTIC TANK ❑ Type/Mf <br /> � 9 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> i Distance to nearest: Well Foundation Property Line ((� <br /> e I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearestr Well —. '"Foundation Property Line <br /> SEEPAGE PITS it Depth Size Number <br /> SUMPS CI Distance to nearest: Well Foundation Property Line P <br /> -.DISPOSAL PONDS F) <br /> "Tt! 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 /> 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 subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> E The applicant must call for all required inspections. Comple drawing on reverse side. <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMEN USE ONLY <br /> Application Accepted by Date � Area <br /> Pit orro t Inspection by Date �/� Final Inspection by r Date -�d <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 />.t <br /> FEE AMOUNT DUE AMOUNT REMITTED CK It <br /> RECEIVED BY j <br /> kNFO CASH DATE PERMIT'NO. <br /> k <br /> H 13-24{REV.i i r<51 /U <br /> H t4-2890 <br /> )-os co - <br />