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r APPLICATION FOR PERMIT fj <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E 1601 E. HAZEL I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 L <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t;,t,: (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. , JE c �J� <br /> •Job Address 3 7 q T ! Pu City S kM Lot Size I ��� PM <br /> Owner's Name s Address Phone W <br /> Contractor's Name icense_No. t i-�" d`Q �� " Phone <br /> TYPE OF WELL/PUMP:? NEW WELL ❑ WELL,REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />€ INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t/fel <br /> 1-1Industrial L1 Open Bottom ❑ Manteca Dia. of Well Excavation' s' Dia. of Wel! Casing <br /> Type <br /> . <br /> ❑ Domestic/Private ❑ Gravel Pack LlTy <br /> Tracy pe of Casing Specifications <br /> ❑ Public ❑ Others t i ❑ Delta Depth of Grout Seal y Type of Grout <br /> ❑ Irrigation ___4pprgx.,Depth ❑ Eastern Surface Seal Ir s_ii d by _.^- <br /> Repair Work Done C1 Type of Pump G N.P _ State Work Done A <br /> Well Destruction ❑ Well Diameter I Sealing Material {top 50'i <br /> Depth —__ - Filler Material (Below,501 <br /> TYPE OF SEPTIC WORK: •NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> r, �Y• � s mss, <br /> InstallatioA will serve:-.-R��e]sidence✓ommercial_ ther <br /> S Number of living units?t�". tNum`ber of bedrooms 7 <br /> "'- GFlaracter of soil to s tlepth of 3�feet: 1 Water table depth <br /> SEPTIC TANK 1 C��ype/Mfg f _ ' _ Capacity No. Compartments <br /> PKG. TREATMENT PLT: ElMethod of Di gaol <br /> � j <br /> Distance to nearest: Well . Founda"tioif Property Line <br /> LEACHING LINE t �I�lo. & Length of lines Total length/size <br /> FILTER BED '"' ❑ Distance to nearest: Well, Foundation I Property Line <br /> �' <br /> IMF, I <br /> I SEEPAGE PITS " �Depfh (Size Slumber <br /> SUMPS ­4 ❑ Distance to nearest: Well Foundation 5 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 following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in subh manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> cerrif,e a 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 o alifornia." 1 <br /> I. The applicant call for a req 'red ins cti s. C late drawing on reverse side. <br />{ 5igne } Title: Date: —/- r <br />' FOR DEPARTMENT USE ONLY <br /> k Application Accepted by Date Area <br /> Pit or Grout Inspection by` (( Date r { Fi I !n pection by TM Date <br /> Additional Comments: 14 <br /> 44�_ttk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 839-6M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH--] <br /> RECEIVED'BY DATE PERMIT NO. <br /> .' S _ <br /> +EH 1324{REV.10l8X <br /> EH 1426 � <br />