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5 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> Job Address _ 50 ff <br /> 5� Ci of Size PM <br /> Owner's Name til n�-tel- Address <br /> ,Phone <br /> Contractor�,__F=E-WACT Li Address O f, <br /> TYPE OF WELL/PUMP: License No. Pho <br /> WELLne 9 d <br /> NEW Li REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LJ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD._ PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ff Manteca Dia. of Well Excavation <br /> I-) Domestic/Private ❑ Gravel Pack Dia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> LJ Public El Other C1 Delta Specifications <br /> of Grout Seal Type of Grout J <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by N <br /> Repair Work Done 12 Type of Pump H.P. <br /> Well Destruction 1-1WeilDiameter State Work DoneJQ <br /> Sealing Material (top 50') I -0Depth Filler Material (Below 501) i -0 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION EPAfR/ADDITION ❑ DEST_RUCTION ❑ (No septic system permitted if public sewer is 0 <br /> { available within 200 feet.) <br /> Installation will serve: Residence—.L---Commercial i 'O-ther <br /> Number of living units:-1— Number of bed <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity���- No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation J Method of Disposal <br /> Property Line it)(Z_ <br /> LEACHING LINE Z--No. & Length of lines Total length/size r <br /> FILTER BED ❑ Distance to nearest: Wellr I_0 Foundation <br /> f'�'-�- Property Line�I n <br /> SEEPAGE PITS M,--b`epth -S ize <br /> SUMPS � Number <br /> ❑ Distance to nearest: Well Foundation--7 Property Line <br /> DISPOSAL PONDS ❑ <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 fallowing: "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 com <br /> certifies the following: pe�sation laws of California." Contractor's hiring or sub-contracting signature <br /> g:"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 /> tlon la f California." <br /> The applican c II for all aqui ins ction . o late awing on averse side <br /> Signed <br /> itle: <br /> Date: <br /> F R ARTMENT USE ONLY <br /> Application Accepted by I!ter <br /> Date !! ,may Area <br /> Pit r�Gr ut In n by ate Final <br /> —04-- <br /> 4 !, ' Inspection by Date <br /> Ad ti a o merlfa- 7 OP. <br /> yV h <br /> ❑ Stk 466-8781 ❑ Lodi -3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 <br /> FEE SAM <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY <br /> CASH DATE PERMIT'NO. <br /> + ER 13-241REV.1/851 C"a• b{� q ,Y` <br /> EH 14-28 Z] C]C_s 1 1 Ztia <br /> �b-}S� <br />