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= APPLICATION FOR PERMIT <br /> SAN JOAQUIN,LOCAL HEALTH DISTRICT S <br /> 1601 E. HAZELTOWAVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> } PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> k (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 /> coo- <br /> Contractor <br /> b Address p <br /> City Lot Size '� PM <br /> ner's Name !9 ) " <br /> 0 Address ti Phone <br /> Address X` License No. <br /> Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT d DESTRUCTION ❑. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE T6-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 <br /> s ❑ Industrial %., ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta h <br /> I J Depth of Grout Seal Type of Grout <br /> ❑ lrrigation l --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Ddne., 1E] Type of Pump f H.P. °�_ =r` t <br /> State Wdrk Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) V� <br /> r <br /> } Depth Filler Material fi3elo ') <br /> TYPEtOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ZfDESTRUCTION El (No septic system permitted if public sewer is S I <br /> available within 200 feet.) <br /> Installation will serve: Residence le— Commercial= Other <br /> r-" Number of living units: ~'�x Number of bedrotms7 <br /> fi <br /> Character of soil to a depth of 3 feet:: <br /> Water table depth <br /> PKG. TREATMENT PLT. <br /> t SEPTIC TANK RJCI5'�,�TYpe/Mf ' '- � <br /> t gCapacity- No. Compartments <br /> F1 <br /> i Method of Disposal <br /> Distance to nearest: 'Well Foundation Property Line <br /> " .t AAGHING LINE C�' No. Len th of lines f <br /> 8 notal length/size"f 6 <br /> " ,4FILTER BED ❑ Distance to nearest: '" Well �G!?S _� Foundation /0 Properly Line <br /> r SEEPAGE PITS ❑ Depth Size '3 1' s t _ f <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation f r Property Line <br /> DISPOSAL PONDS ❑ ) { If <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 a§to become subject lo-workman's compensation laws of California:"'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 st all for all required inspections. Complete drawing on reverse side. " <br /> Signed Title: <br /> Date: <br /> OR DEPARTMENT USE'ONLY <br /> Application Acceptio <br /> r k Date !J- <br /> Area <br /> Pit or Grout Inspe <br /> _J <br /> ' r` <br /> Date Final Inspection by Date <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 JJ AAA,. <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> -7CK RECEIVED BY <br /> INFO DATE PERMIT'NO., <br /> +EH M24(REV. H 5) <br /> EH 1428 <br />