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M Z <br /> APPLICATION FOR PERMIT <br /> SAN. JOAQUfN LOCAL HEALTH DISTRICT L <br /> t <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> t 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 City Lot Size PM <br /> Owner's Name Address / YWb pz^--(o�,y tv <br /> Phone <br /> Contractor " Address <br /> License No. Phone <br /> t TYPE OF WELL/PUMP:xA NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT IFICATIONS <br /> ❑ Industrial Q Open Bottom ff Manteca Well Excavation Dia. of Well Casing <br /> El Domestic/Private Ll Gravel Pack ❑ T Type of Casing— Specifications' r <br /> f'1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i y. <br /> I I Irrigation rox. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump —H,.P. State Work Done'_ kA <br /> Well Des ion ❑ Well Diameter Sealing Materialultop 501 t <br /> y <br /> � �.: Depth- Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: ' NEW INSTALLATION I'1 REPAIR/ADDITION I.I DESTRUCTION (fVo septic system permitted it public sewer is <br /> available.within 200 feet.) <br /> Installation will serve: Residenceft— Commercial_ :Other <br /> Number of living units:. Number of bedrooms j <br /> t Character of soil to a depth of 3 feet: Water table depth <br /> I <br /> 'SEPTIC TANK ❑ ,`Type/Mfg Capacity No. Compartments <br /> I PKG. TREATMENT PLT. ❑ i <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line` <br /> k LEACHING LINE Cl No. & Length of lines ! - t Total length/size- f <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 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 such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies 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 laws of California." <br /> nt us call or all req 'ed inppactions. Complete drawing on r verse side. <br /> Signed X Title: �p . J <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date rea <br /> Pit or Grout Inspection by Data Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 [7 Manteca 823-7104 ❑ Tracy 835 6385 v I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0..17 <br /> I <br /> INFO CA W <br /> +.EH13-21fREV.fin51 3S <br /> EH 11-28 <br /> 9 <br />