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— — APPLICATION FOR PERMIT --° "" <br /> h n <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ' <br /> Telephone 1209) 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. �7 <br /> ` Job Address + '+ l ` lir^:�1 e—, 4 . City '�' Lot Size ' r PM <br /> r k <br /> Owner's Namer <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 11 WELL REPLACEMENT EJ f 7 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 0 <br />} DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FID. PPOP, LINE <br />` FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial i ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private D Gravel Pack ❑ Trac Type ype of Casing Specifications <br /> ['1 Public 171 Other f1 Delta Depth of Grout Seal Type of Grout <br /> i I ) Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> t Repair Work none ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 _ <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIOPAIQ REPAIRlApDITION I I DESTRUCTION l I Mo septic system permitted it public sewer is <br /> available within 200 feet.) <br /> i <br /> Installation will serve: ResidenceAr Commercial_ other <br /> Number of living units: _ � Number of bedrooms <br /> a Character of soil to a depth of:3 feet: Irr _ Water table depth <br /> SEPTIC TANK' O'"7ype/Mfg f r Capacity ` No. Compartments <br /> PKG. TREATMENT PLT. ElMethod of Disposal <br /> Distance to nearest: Well Foundations f Property Line <br /> I - <br /> LEACHING LINE &—No. &Length of lines � r <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> r t Foundation Property Line <br /> SEEPAGE PITSI nepth - <br /> _size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Properly Line <br /> ¢ DISPOSAL PONDS L7 <br /> I hereby certify that I have prepared this application and that the work will be donu in accordance with Sart Joaquin county ordinances, state laws, and <br /> f rules and regul#tions of the San Joaquin Local Health Dilttict. <br /> g <br /> fl� <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of{he,work for which this permit is issued, I shalt 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 loll'wing; "I cattily that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compansa- <br /> lion laws of California." I <br /> The applicant must call for all required inspections. Complete dr wing on reverse side. <br /> Signed r I Date: ' <br /> ! FOR DEPARTMENT US&ONLY' } <br /> Application Accepted by � � <br /> .. Date- -rf � Area <br /> Grout Inspection, by' Date ' <br /> Final Inspection by <br /> it Data w�. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK Y RECEIVED <br /> INFO CASH 8 GATE PERMIT'NO. <br /> 4 , EH1324(REV <br /> .r:nSl ,74r� ry � <br />