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V4 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-67$3 <br /> PERMIT EXPIRES 1 YEAR FROM DATE,ISSUED W a <br /> 0. <br /> ;tis, , z `+ .•r,± . .��� , R{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 />� <br /> Job Address <br /> r ; City Lot Size PM <br /> Owner's Name r L s 'Address <br /> Phone <br /> Contractorcc�Aadtess License No. Phone <br /> J <br /> TYPE OF WELL/PUMP: t NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION '❑ <br /> PUMP INSTALLATION E] SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES s <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION - <br /> AGRICULTURE WELL- W <br /> f OTHER ELL „ PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dial. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C1Public ❑ Other ❑ ,Delta 'Depth of Grout Seal <br /> Type of Grout <br /> El ..—Approx. Depth ❑ Eastern - Surface Seal Installed by', <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done_ <br /> Well Destruction ❑ Well Diameter i Sealing Material (top 5o') t <br /> Depth € Filler Material {Below 50') I j. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION { eptic system permitted if public sewer is <br /> i" I available within 200 feet.) <br /> Residence_ Commercial <br /> Installation wiil serve: _ Other <br /> Number of living units: Number of bedrooms q <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 4 ; <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ - 't �' <br /> Method of Disposal <br /> Distance to-nearest: Well Foundation ^- .Property Line <br /> LEACHING LINE ❑ No. &!Length of fines <br /> Total length/size 1 <br /> FILTER BED ❑ Distance to nearest:- Well Foundation <br /> 4 1 Property Line <br /> SEEPAGE PITS ❑ DeOth Size Y- `I <br /> Number <br /> SUMPS . ❑ .Distance to nearest + Well Foundation r - Property Lirie <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and'that the work,will b6-done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Districf s- t <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 nor <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• i <br /> ce es 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 la f Californ a." <br /> applic t callr al equir ins ion C mplete drawing on r verse side <br /> Signed r Title: <br /> Date: ((( <br /> 4 = FOR DEPARTMENT E ONLY hi <br /> .� w <br /> Application Accepted by Date �/ SCJ p <br /> _ Area � V <br /> Pif or Grout Inspection by a�_- Date Final Inspection by /� Date <br /> Additional Comments: <br /> I C] Stk 466-6781 1 ❑ Lodi .369-3621 Manteca .823-7104 ❑•Tracy 835-6385 <br /> Applicant Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 <br />