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I APPLICATION+OR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone Q091 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i 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 /> Job Address r( led,- _City Lot Size PM <br /> i <br /> ��i <br /> q <br /> Owner's Name Address J Phone 3 <br /> Contractor 11:dress frCSt� Lit ense Ni). 34 2 Phone x *rT <br /> TYPE OF WE RJEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> e PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST:*SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> -..�_ ~v <br /> FOUNDATION AGRICULTURE WELL OTHER WELT PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation 4 Dia. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications ' r <br /> k M Public ❑ Other ❑ Delta Depth of Grout Seal Type.of,Grout <br /> I I Irrigation _..Approxi Depth I I Eastern Surface Seal Installed by <br /> ' <br /> Repair Work Done L-) Type of Pumpc H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I <br /> el Filler Material /Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION l I (No septic system permitted if public sewer is <br /> . <br /> available within 200 feet ) <br /> � f <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of be oo s <br /> Character of soil to a depth of 3 feet'. Water table depth <br /> SEPTIC TANK ❑ Type/Mfg r icT cap jity_{rZ� No. Compartments <br /> PKG. TREATMENT PLT.❑ S /Method of Disposal r <br /> Distance to nearest: Well �Qd Foundaation Property Line <br /> I <br /> LEACHING LINE No. & Length of lines -- r �Totalngth/sizeFILTER BED ❑ Distance tonearest: WeII_f� FoundationProperty Line 1 vo <br /> SEEPAGE PITS Depth ` Size Number " <br /> SUMPS L7 Distance to nearest: Well� Foundation _ Property Line— , <br /> DISPOSAL PONDS Elx C <br /> ?E <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 /> :;-H <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 C nia." <br /> The appl1i n mu c f all re omplete drawing on re erse side. <br /> Signed X .- <br /> g Title: Date: ) <br /> FOR DEPARTMENT USE ONLY ti <br /> Application Accepted bjby <br /> Date _ r Area <br /> Pit or Grout Ins �[p <br /> pection Date ° Fin I Inspection by Dates I <br /> ' <br /> X <br /> ditional Comments: <br /> t <br /> Stk 466-6781 Q Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 _ <br /> f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE 1 ERMIT N0. <br /> + E 13-24(REV.i/x 51 �-� ( �^ 'l' 47 UA7 <br /> EHH 14-2t3 U �"� v! 7`� <br />