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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 I <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 weii/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Lot Size PM <br /> , City �. <br /> Job Address /y <br /> l s a Phone <br /> Owner's Name <br /> F icense NqC Phone D <br /> µ Contractor dress e <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELLSYSTEM REPAIR ❑REPLACEMENT ❑ DESTR OTHER El <br /> INSTALLATION ION ❑ <br /> S <br /> SEWER LINES <br /> DISPOSAL FLD. <br /> DISTANCE TO NEAREST: SEPTIC TANK POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS;-_ f <br /> I ❑ industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia"of Well Casing <br /> Type of Casin Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy YP -. 9` <br /> 1­1 Public H Other `� C1 Delta..Y Depth-of Grout Seal -� Type of Grout <br /> I l Irrigation —.-Approx. Depth i I Eastern • Surface Seal installed by <br /> H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth -''f Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l REPAIRlAODITION I I DESTRUCTION l I avaiiablelwithin e200 feet.) if public sewer is <br /> ff ,�/ <br /> a r' <br /> Installation will serve: Residence C_ommercial'�{ Other <br /> Number of living units: ' Number of bedrooms\4� `' `" F y <br /> a+'�.. ; Water table depth <br /> Character of soil to a depth o1 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg - Capacity NoY Compartments <br /> PKG. TREATMENT PLT. 1-1Method o Dis osal <br /> Distance to nearest: x Well C/ -- Fo d ion !� Property`Line <br /> LEACHING LINE ❑ No. & Length of lines Total-length)size <br /> FILTER BED ❑ Distance to nearest: Well Foundation _ — Property Line -- <br /> I SiNumber` <br /> SEEPAGE PITS 11 Depth ze <br /> laTMP ❑ Distance to nearest: Well Foundation Property Linev <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 /> f 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 /> The applicant st cal all uire -ins ct ns. Completed ing erre side. <br /> Title: Date: <br /> Signed X v <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by NNI nilz Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date—8--1,04-7 <br /> A ditional Comments: <br /> Sik 466-6781 El Lodi 369-3621 13 Manteca 823-7104 ❑ Tracy 835 6385 <br /> plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASK RECEIVED [3Y DATE PERMIT NO. <br /> INFO <br /> . EH 1324 lgEV.i i n sr (2V <br /> EH 14-28 <br />