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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or NLocal Health District for a permit to construct and/or install the work herein described. This application is <br /> o. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> al Health District. <br /> City Lot Size r "� PM <br /> Job Address z <br /> Owner's Name�j _. � s 1y�� ���u-IrAddress f r1 <br /> �— Phone <br /> 40,r License No._Phone_ <br /> Contractor Address <br /> E OF WELL/PUMP: NEW WELL-171 REPLACEMENT:❑,.t jDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR L1j `' OTHER ❑ <br /> SEWER LINES SAL FLD. PROP. NE <br /> DISTANCE TON EST: SEPTIC TANK j PLINE <br /> OUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE ELL PROBLEM AREA TRUCTION SPECIFICATIONS Dia of Well Casing <br /> ❑ Industrial L] Open Bottom ❑ Manteca- Dia.—of-Well.Excavation Specifications <br /> Type of Casing <br /> ❑ Domestic/Private 0 Gravel Pack ❑ I Type of Grout — <br />' f! Other Cl Delta` epth of Grout Seal <br /> l`1 Public <br /> I <br /> I V Irrigation _ Apprax epth i I Eastern Surfac Installed by <br /> Repair Work Done 0 Type ump H.P. <br /> Well Destruction ❑ ell Diameter State;Work Done <br /> ' Sealing Material (top 5011 <br /> I <br /> I Filler Material (Below 50'1 <br /> t Depth t) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [SI REPAIR/ADDITION l 1 DESTRUCTION ,availseptic system <br /> ithin 20l)feett�jed if public sewer is 1 <br /> l Installation will serve: Residence.— Commercial Other <br /> t Number of living units: __ Number of bedrooms <br /> i � t� �--• — � Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK 0 Type/Mfg <br /> ` � Capacity No. Compartments <br /> Method of Disposal <br /> 4 PKG. TREATMENT PLT. 0 s '� <br /> } Distance to1nearest: Well Foundation Property Line- �• <br /> ! Total length/size <br /> LEACHING LINE 0 +-No:;& Length of lines �{ <br /> '�^� Foundation Property Line <br /> FILTER BED El Distance to.nearest: 1IVelI <br /> SEEPAGE PITS l I 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." 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> applica us call for all re ired inspections. Complete drawing on reverse side.,The <br /> [ (_ �` Title:�,; Date: <br /> Signed zC <br /> FOR DEPARTMENT USE ONLY <br /> Date y Area <br /> Application Accepted by t�Q <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date 3—7,0 <br /> sir - r I(04 �21 <br /> Additional Comments: �� ' S <br /> r <br /> ElStk 466-6781 11 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. Bax X109, Silk., CA 95201 <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY ;WDATE PERMIT NO. <br /> INFO <br /> I1 s S <br /> +.EH 13-24{REV.t i n 5) <br /> EH 14-2e <br />