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APPLICATION FOR PERMIT s� <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) —,v <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 welli pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> Y4 City�.�Z-a —L-L�/Lot Size 7 TPM <br /> • �:' rte" <br /> Phone <br /> fkk Owner's Nam • cAddr�ess, <br /> i Address �� �''- -�� License Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION fi . <br /> PUMP iNSTAL(ATION ❑ SYSTEM REPAIR C OTHER O W <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES PITS/SUMPS <br /> t FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> Industrial C Open Bottom ❑ Manteca Dia. of Well Excavation. — <br /> rSpecifications <br /> 0 Domestic/Private L7, Gravel Pack C1 Tracy Type of Casing <br /> +I f" Public <br /> _r Other R Delta Depth of Grout Seal Type of Grout <br /> Irrigation -Approx. Depth I I Eastern Surface Saul installed by <br /> j Repair Work Done 0of Pump H.P. _ State Work ne <br /> j` SealingMaterial Itop 50') <br /> Well Destruction Well Diameter � <br /> Depth o7 B Filter Material (Below 50'1, ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I ' ahvailableo septic sYsI M rented if public sewer is <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms r <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ` SEPTIC TANK a Type/Mfg Capacity No. Compartments �r <br /> r PKG. TREATMENT PLT.❑ Method of Disposal <br /> it <br /> i Distance to nearest. Well Foundation Property Line`. � <br /> r <br /> LEACHING UNE G No. & Length of lines ____ �. '`Total iength/size' <br /> II FILTER BED G Distance to nearest: Well_._ Foundation '� .Property Line <br /> SEEPAGE PITS I ! Depth Size Number e <br /> s = ' <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ *. t <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 /> I r <br /> rules and regulations of the San Joaquin'Local Heafth District. ' <br /> Home owner or licensed ageni's-signature certifies the following: -I certify that in the performance of the work for which this perrrdt is issued, I,shall not:, ' <br /> employ any person in such manner is to_become subject to workman's compensation laws of California." Contractors hiring or sub-contracting,s' nature <br /> sub `cortrpens <br /> certifins the following: "I certify that in the¢er�rm�ce of the work for which this permit iisjsued,I shall employ persons subject to workman, <br /> tion laws of California." �f ` J <br /> t The applicant must caH for all requi�nspactioComplete drawing on reverse side. rXSignedX -� �� Title: �-��t�1'�`! Date: <br /> 3 FOR DEPARTMENT USE ONLY Y <br /> M <br /> f t ''"Area <br /> t Application Accepted by Date <br /> H <br /> Pit or Grout Inspection by ate_ Final Inspection by <br /> Date <br /> ;r <br /> _ s <br /> Additional Comments: <br /> C Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823.7104 C Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. I aImltcn Ave., P.O. Box 20UA, Sik.,'CA 95201 �•?� ��c, 1 <br /> �J <br /> FEE AMOUNT DUE,� a, AMOUNT.REMITTED CASH �RECEIVED BY-.v 1 ,DA PERMIT'NO. '� <br /> INFO <br /> EH13324(REV.i <br /> F EH 71-26 - <br />