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t APPLICATION FOR PERMIT <br /> l ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j" 1601 E. HAZE.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 <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 /> Cit el <br /> PM <br /> Jab Address <br /> e /�} e <br /> r Owner's Name''/ two, ddress +U r <br /> P 11 <br /> Address License NP one <br /> p Contractor(-T L, ` <br /> r TYPE OF WELL/PUMP: NEW WELL�' WELL REPLACEMENT 1-1DESTRUCTION ❑ <br /> PUMP INSTALLATION p� SYSTEM REPAIR ❑ OTHER ❑ <br /> r DISPOSAL FLD. PROP. LINE <br /> DISTANCE,TO NEAREST: SEPTIC TANK.,. Sim_— SEWER LINES <br /> I" FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TY E OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r� <br /> ❑ itydUstrial Pe <br /> n Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> L_�/ Type of Gasin � 5pecitications �I <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy yp g Type of Grout <br /> f"1 Public Cl Other ❑ Delta Depth of Grout Seal <br /> t 0aA rox. Depth I Easternuface Sea! Installed by <br /> I I Irrigation - pP �d <br /> Repair Work Done ❑ Type of Pump �sFJ H.P. State Work Done_ C� <br /> Well Destruction ❑ Well Diameter Sealing.Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE10F SEPTIC-WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I (No septic system <br /> permitted if public sewer is <br /> availabInstallation will serve: Residence Commercial — Other' . <br /> ' Number of living units. Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ' PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Prooerty.Line <br /> LEACHING LINE ❑ No. & Length of lines Tota! length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'] Depth Size Number <br /> SUMPS L-) Distance to nearest: Well Foundation Property Line <br /> 1� <br /> DISPOSAL PONDS ❑ <br /> k 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 /> emptoy any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> cartifies 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 ust II for all requir inspe tions. Complete drawing _on rgu$rsed <br /> ' Title: }}���lrl Date: �J <br /> Signed X <br /> 4, FOR DEPARTMENT USE ONLY <br /> Dat Area s2 � <br /> Apptication Accepted by <br /> Pit or Grout Inspection by <br /> pate�� Final Inspection by "yz Date 4d <br /> Additional comments: <br /> ❑ Stk 466-6781 �, 369�-3621 ❑ Manteca 823- 104 ❑ T cy 5-6385 <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 H REC VEO BY DATE PERMIT'NO. <br /> INFO r/ J17� <br /> •.EH 13.24(REV.1 51 <br /> EN 14-26 J <br />