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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �' '•f^ � <br /> 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 SanJoaquinLocal 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 /> Job Address k= City_449;t�ot Size PM <br /> Owner's Name dress <br /> Phone <br /> Contractor Address / Lic e No. Plane <br /> TYPE OF WELL/PUIVIP: NEW WELL-❑— WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAR SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FO TION AGRI,CU.LTURE WELL OTHER WELL PITSISUMPS _ <br /> INTENDED USE TYPE OF WEL PROBLf6A'IiEA-�CONSTR CIFICATIONS <br /> ❑ Industrial C] Open Bottom ! <br /> p ; teca T ,-615­6f. Weil Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 11 Gravel Pack ' ❑ Trac Type of Casing Specifications <br /> (1 Public Y F] Other } elt � th of Grout Seal Type of Grout {� <br /> i I Irrigation �_Approx. Dep i.JJJ,Eastern� Surfac. _ Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done } <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> yf Depth Filler Material (Below 50" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ul. Installation will serve: Residence Commercial_ Other (� <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg) Capacity No. Compartments . <br /> PKG. TREATMENT PLT. ❑ Method of Disposal : I <br /> Distance to nearest: Well Foundation <br /> 4; Praperty.Line <br /> ` I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size A'° Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ a <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 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 Califo a. i j <br /> r - <br /> The applicant t c for all re ui d inspections. Complete drawing on ireverse side. ! <br /> Signed X 41007 4dP47 <br /> Title: Date: I <br /> t1.AV <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by , <br /> Date Area <br /> Pit or Grot1lnspecf by Date Final Inspection by Date <br /> { <br /> Additional`Comm , <br /> _j ❑ Stk 466-67,81„ Lodi 369:362.1 ❑ Manteca .823-7.104 ❑.Tracy-_835.6385 Y _ <br /> Applicant - Return'all 0106s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CR <br /> FEE <br /> ?1 INFO AMOUNT DUE " AMOUNT REMITTED j rC- SH w+*RECEIVED 9Y a DATE _ PERMIT Nd. <br /> r +EH 13-24(REV. <br /> EH 1138 � �R. �. � 11 - .I 1�� �•S/ ��( w+a7 <br /> ' f LL 1 s <br />