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I: <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA fork � . <br /> Telephone (209) 466-6781 <br /> i; PERMIT EXPIRES 1 YEARrFROM 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 /> _.,.. <br /> Local Health District. <br /> 7 l n�t1i. <br /> Lot Size <br /> ( S PM 4 <br /> JCity <br /> (Job Address — <br /> r f Phone <br /> .Owner's Name 'Address <br /> 1 <br /> I Address icense No.� Phone <br /> lConiractor�( II�J-� <br /> (TYPE OF WELLIPUMP: NEW WELL ❑ <br /> WELL REPLACEMENT E3DESTRUCTION LJ } <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> TDISTANCr'M��TICTANKSEWER LINES DISPOSAL FLD. PROP. LINE <br /> NDATIO AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TION SPECIFICATIONS <br /> 1 Dia. of Well Casing <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatio <br /> of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type g <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal-, Type ut <br /> ❑ Irrigation Approx. Depth El Seal Installed by <br /> !; <br /> j Repair Work Done ❑ Type of Pump <br /> H.P. i State Work Done <br />` Well Destruction ❑ Well Diameter Sealing Material'(top 501 <br /> Depth Filler Material (Below-50') <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIH/ADDITION.❑ DESTRUCTION ptic system permitted if public sewer is <br /> fi .- available within 200 feet-1 <br /> installation will serve: Residence` Commercial_ Other <br /> Number of living units: �� Number of bedrooms <br /> i <br /> � Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT- ❑ ! r <br /> Distance to,nearest: ell t '0 Fo_undation, Property Line <br /> I� F0=1 \ <br /> _ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ »Distance to nearest: Well n Foundation Property Line <br /> SEEPAGE PITS ❑ [Depth Size Number <br /> SUMPS ❑ :1,Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll l <br /> I hereby certify that l 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 /> I '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 fallowing: "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 s of California." <br /> The appi0a must call for II required spe ion Complete draw;ng on r erse side t I <br /> Title: Date: <br /> Signed _ <br /> FQR AR7MENT SE ONLY <br /> /5 <br /> Application Accepted by i <br /> Date Area <br /> h Date <br /> Pit or Grout Inspection by bate Final Inspection by <br /> R Additional Comments F r x "' <br /> w. I ❑ Stk 466 6761 ❑ Lodi 369- ❑,Man`teca� ,823-7104 -, fl ,racy 835-6385 ♦(. <br /> Applicant- Return all copieslto: Environmental HealfFi Permit/Services 1601 E.`Hazelton Ave., P.O. Box 2009, Stk., CA 95201 „ <br /> 10s .r � u, <br /> FEE - K RECEIVED BY DATE PERMIT'NO. <br /> INFO AMOUNT DUE' AMOUNT REMITTED <br /> + EH 13-24{REV.t x s <br /> %I,, V 4-9s Lo C� <br /> JEH 14-28 `; - <br />