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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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-San Joaquin,Local Health'District for a.permit to construct and/or install the work herein described. This application is <br /> made in compliance-wifh 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 /> 131 yy\ <br /> Job Address :S+ City _b. <br /> Lot Size PM <br /> i <br /> �,. <br /> Owner's Na�m�e� ,.L Address Phone <br /> I <br /> Contractor1/S�_��1 �=_ Ad`dr ss_ D "License No. 309A&IPhone <br /> TYPE OF WELL/PUMP:-----•- --NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ e <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 <br /> ❑ Industrial . ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation --Approx. Depth I I 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 Materiai (Below 56 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/)0DITION l L TRUCTION I 1 INo septic system.permitted-if-public-sewer is <br /> available within 200 feet.► ? <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> - x <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ T e/Mf ` <br /> Yp 9 Capacity No. Compartments , <br /> PKG. TREATMENT PLT. ❑ Method of Dis sal <br /> Distance to nearest: Well�— Foundation -- Property Line <br /> K <br /> LEACHING LINE "WCw"l— Length of lines Total length/size (� <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> SEEPAGE PITS � epth Size-qk Number ' <br /> SUMPS t_71 Distance to nearest: Well Fou dation Property Line .f ' <br /> DISPOSAL PONDS 0 L� c— <br /> DISPOSAL <br /> I hereby certify that I have prepared this application and that the work willl,be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District.- fi , <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 /> ce ' ' the following: "I certify that in the performance of the work for which this permit is issued, f shalt employ persons subject to workman's compensa <br /> do laws alifornia." 1 <br /> The applicant u all for requir ins do C late drawing on reverse si i <br /> Signed X aTitle: <br /> Date: �°^.-~!,��—g, <br /> r FOR DEPARTMENT USE ONLY 1 Q <br /> Application Accepted by V L� a fl <br /> Data- 'y '� p. ,Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: t r <br /> ❑ Stk 466-67$1 Cl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy ,835-6385 I <br /> Applicant- Return all copies to: Environmental Health-Permit/Services 1601 E. Hazelton Ave.,-P.O. Boz 2009, Stk., CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> INFO -+� CAS <br /> + EH13-24 IREV.I/ <br /> n 5) r � <br /> EH 1428 rf20, <br />