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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1r , <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. Thi§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 Joaquiri <br /> "Local Health District. ; <br /> Job Address 4- ;1 ,4N 7 City Lot Size, r <br /> Owner's Name � Address ��d Phone L C� <br /> einContractor's Namese,No.. _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL 9;— ' WELL REPLACEMENT+'O ""DESTRUCTION`❑''' <br /> -'PUMIF INSTALLATION ®�" p SYSTEM RE IR""❑,�" ^.5-- -OTHEFi""❑'�—_ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLDr PROP. LINE <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL"`- PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS• <br /> ❑ Industrial Bottom ❑ Manteca Dia. of Well Excavati n Dia. of Well Casing <br /> E-BG 1 stic/Private El Gravel Pack 4 El Tracy Type of Casing Specifications <br /> O Public ❑ Other `�❑ alta Qepth of Grout Seal �� j Typei f <br /> Q irrigation 'Approx�Depth�` stern -*-�*---Surface Seal Installed'by <br /> Repair Work Done ❑ Type of Pump-� *-H.P.�_.. State Work.;Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> ! w <br /> F ti t Depth 1 Qd Filler Material {Below 501 <br /> } TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> i Iris allation will serve: Residence_ Commercial_ Other Q <br /> i Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet-"`—'"""` �` Water table depth <br /> SEPTIC TANK' ❑ ,Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1Mdthod of Disposal <br /> f - a.. _ ,Distance-.ta.nea�est:,;Q_Well_ - Foundation - Property Line <br /> LEACHING LINE ❑ No. & Length of lines n <br /> 9 Total length/vsizeL- a <br /> s FILTER BED ❑ Distan e-to. en arest: Well Foundation Property/Line %� 4 <br /> SEEPAGE PITS ❑ Depth_ Size Number <br /> f.r I <br /> SUMPS ❑14Distance 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 courity oidirlances, 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 /> 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 /> 4 The applicant mus II for all required inspections. Complete g on reverse side. <br /> Signed Title:_- Date: <br /> FOR DEPARTMENT t1SE ONLY <br /> .Application 6ffepted by Date C1 ~ Are <br /> Pito Grout spection by Date 7-7// S� Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 389-3511 1:1Manteca 823-7104 C3Tracy 835-6385 <br /> Applicant- Return all co ies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE " <br /> INFO AMOUNT DUE AMOUNT REMITTED C SH RECEIVED BY DATE PERMIT'NO. <br /> + EH13.241REV.10/831 `1 � �5 + <br /> EH 1428 �� "�O 1 rCa 53 S _7 i <br /> �: <br />