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i <br /> z <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> 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 /> 4 made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1851 for well/pump and the Rules and Regulations of the San Joaquin <br /> i Local Health District. ;1 <br /> Job Address 16 $61-1a City Lot Size PM <br /> Owner's Named Address Phone <br /> Contractor's Name .. License No. � � Y P h one'-V t, <br /> : TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> p PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> o- DISTANCE TO NEAREST: SEPTIC TANK SEINER LINES DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL �� £PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom*r' ❑ Manteca Dia. of Wel! Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack{ ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ( ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> k Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> { Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> +1 ; TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is _ <br /> available within 200 feet.) <br /> ' Installation will serve: Residence L. Commercial—— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK E Type/Mfg Capacity �No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest, Well Foundation Property Line <br /> ! `� 2. Total len th/size �- <br /> � LEACHING LINE � No. &Length of lines 9 <br /> �` <br /> FILTER BED w '. ❑�Distance.So nearest: Wel!5 Foundation�p Property Line <br /> f" _ Number <br /> SEEPAGE PITS `:- ❑ ) Depth �- Size " <br /> f: �.-.. j r i <br /> SUMPS' Cl. ;Disstance to,nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ?.,�L] r <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,Lacal Healtl 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 A,o,become subject to workman's compensation laws of'Callfornia."Contractors 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 0rsons-subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must calif alluired inspe omplete drawing on reverse s4e. <br /> t�eq <br /> Signed )L - Title:— �--� Date: <br /> FOR DEPARTMENT USE ONLY <br /> .Application Accepted by :t i 4- Date Q Area <br /> Pit or Grout Inspection by Date Final Inspection by Aw Date <br /> ON6, PIT Dwul,:D 81117 9�, ? ° 6 0 <br /> A4ditional Comments: � UJ <br /> Stk 466-6781 ❑ Lodi 389-36221 #❑ Manteca 823-7104 C1 Tracy 1fiS �� 1 �t✓T <br /> A plicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEMITTED RECEIVED BY, DATE . <br /> INFO AMOUNT DUE AMOUNT RE CCKASH PERMIT <br /> + EH 13-24 IREV.10183) J •"+ <br /> EH 1428 <br /> 1 <br />