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{ <br /> h APPLICATION FOR PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 <br /> liitoDistrict <br /> permit <br /> construct <br /> install <br /> ulns application <br /> made ncomplianceance wh San Joaquin County Ordinance No.549 for sewage or No. 1862 for nd the Rules and Regulations of he SanJoaquin <br /> Local Health District. <br /> Job Address <br /> City_�6a Lot Size /� <br /> 1 <br /> Phone <br /> Owner's Name dd ass f ' <br /> ir <br /> Contractor's Name 4 <br /> "cense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 0 SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial [JOpen Bottom ElManteca Dia. of Well Excavation Pia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack E] Tracy t Type of Casing <br /> Specifications I <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> } Depth ! ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLA ION REPAIR/ADDITION El DESTRUCTION O (No septic system permitted if public sewer is <br /> a available within 200 feet.) <br /> Installation will serve:Residence V Commercial_ Other x J <br /> Number of living units: --..L— Number of bedrooms <br /> At Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Type/Mfg ' Capacity L_a_� No. Compartments <br /> f Method of isposal' 4 <br /> PKG. TREATMENT PLT.'[], <br /> Distance to nearest: Well ` Foundation Property Line 1/ t <br /> el 42 Total length/size <br /> LEACHING LINE A No. & Length of lines O <br /> FILTER BED ❑ Distance to nearest: Well 1 f Foundation- Property Line'�— <br /> YF <br /> I Y <br /> SEEPAGE PITS ❑ Depthr�01�t size Oumber <br /> 40> 1- bIstance to nearest: Well 9 Foundation . Property Line 5. <br /> i DISPOSAL PONDS F] 1 <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, 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 Califomia." 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 /> The applicant rquqi c r a require i ctions. Comp) to rawing on r r e side. / . <br /> ' Date: yj <br /> Signed Title: _ <br /> FOR DEPARTMENT USE ONLY _ �// <br /> Application Accepted by <br /> Date r -U"' Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> l - <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"NO. <br /> r INFO CASH <br /> + EH 1344(REV.161831 70 O� <br /> EH 1126 <br />