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* l <br /> APPLICATION EOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 /> 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.-7317 <br /> t <br />' \,Job Address J� vp. �i�J City Lot Size PM <br /> Owner's Name �� � v1a�t `� � / Ad resd s <br /> Phone <br /> v I <br /> Contractor dress7icense No Phone <br /> TYPE OF WELL/PUMP:... NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> c ' <br /> -DISTANCE TO-NEAREST:,SEPTIC-TANK w_SEWER.LINES— - D15POSAL FLD. PROP. LINE <br /> FOUNDATION ' AGRICULTURE WELL OTHER WELL r PITS/SUMPS { a <br /> INTENDECCUSE .� TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i f <br /> ❑ Industrial ❑ Open Bottom_ "❑.Mante_ca_%,. Dia. of Well Excavation ` <br /> Dia. of Well Casing 1 <br /> s © Domestic/Private ❑ Gravel Pack ❑ Tracy Type'of Casing Specifications j <br /> *tiy❑ Public a .»,._. i�"OthefY .,—Fl Delta, { Type of Grout hf Grout Seal } <br /> r t <br /> s I I Irrigation __Approx. Depth I I Eastern Surface Seal installed by I—~" <br /> Repair Work Done—0 Type-of;Pump� ^-- i'rH State Work pone <br /> " Well Destruction ❑ Well Diaineter� * \Sealing Material.ftop 50') <br /> 1 <br /> I` +Depthlo' ' Filler Matefial (Below 50'11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION -'f1EPAIR/ADDITION I-]—DESTRUCTION-I'-I-(No-septic-system permitted if public sewer is <br /> F L' <br /> .available within 200 feet.) ..i <br /> Installation will serve: Resid nce�Commercial Other 4 f ' <br /> Number of living units: Number of bedrooms <br /> Character of soil.to a depth of 3 feet: <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartmenfs <br /> PKG. TREATMENT PLT. ❑ i � f <br /> # Distance to nearest: u Well Foundation � -- <br /> - Method of Disposal <br /> i- -� �._._ Property Line ' € <br /> t LEACHING LINE i . No_ & Length of linesTotal length/size <br /> FILTER BED ❑, Distance to nearest: Welll <br /> ff� Foundation 16r7— Property Line i <br /> SEEPAGE PITS 1 I Depth i -SizeE Number <br /> e SUMPS } Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ i <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 per 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 certrfy'that in the performance of the work for which this permit is issued, I snap employ persons subject to workman's <br /> compensa-tion laws of California." ; <br /> The applicant must call for all required inspections. Complete drawing on!reverse side. j <br /> Signed X i t <br /> Title: Date: <br /> FOR EP ENT USE ONLY <br /> f �7 <br /> f Application Accepted by <br /> Date <br /> Area <br /> r Pit or Grout Inspection by Date 1 Final Inspection by Date ! �7 <br /> . ` <br /> i" 1 <br /> "Additional Comments: <br /> t' ❑ StR 466-6781 ❑ Lodi 369-3621 ❑ Manteca` 623-7144 ❑ Tracy 835-6385 <br /> Applicant 7.Retur_pll copies to:.Environmental Health Parmit/Services 1601 E. Hazelton Ave., P.O.;Box 2009, Stk., CA 95201 <br />' FEE AMOUNT DUE AMOUNT REMITTf D ti :+ CK <br /> ._INFO - - -CASH LS_'REC IUED.tlY� DATE,_,.• _ <br /> + EH 13-241REv,.1 45) - <br /> EH 14-26 <br />