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3 <br /> } APPLICATION FOR PERMIT <br /> -:. SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> a <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. 1B62 for well pump and the Rules and Regulations of the San Joaquin <br /> i Local Health District. r <br /> O ' S• r4 /lf CityLF LLot Size PM <br /> Job Address c �Q ArW <br /> Address '�p8� 7 <br /> Owner's Name i� CC c�1 �j <br /> ���,�,,J /(,� Address!•D• License 133a Phone �6'Z 'n <br /> Contraclor�+fw�w> 2 ' <br /> TYPE OF WELL/PUMP: ; NEW.WELL )CWELL REPLACEMENT LJDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHERX MA <br /> DISTANCE TO NEAREST: SEPTIC TANK _. SEWER LINES' DISPOSAL FLD. PROP, LINE [t <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I:' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> ' A— Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> to Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public f Other <br /> Cl Delta Depth of Grout Seal Type of Grout C 'E <br /> I I Irrigation Approx. Depth i I Eastern 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 /> i Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION I I DESTRUCTION I 1 IND seavailabptic sy t em <br /> 200 feet if public sewer is S <br /> L <br /> i Installation will serve: Residence_ Commercial __ Other <br /> 1 <br /> 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 Capaciity No. Compartments <br /> PKG. TREATMENT PLT. LJI . � Method of Disposal <br /> i <br /> � Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑I No. & Length of lines Total length/size I <br /> I FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> } SEEPAGE PITS l I Depth Size Number 0 <br /> SUMPS C-1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Q <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 /> i rtify that in the performance of the work for which this permit.is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "i ce <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 /> { The applicant must call for,all required in ction Co ete drawing on reverse side. <br /> I Signed Title: 644 '41 Date: •23 <br /> .01 <br /> I _ - <br /> i -JFOR DEPARTMENT USE ONLY <br /> 3a <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection byi 4 Date— Final Inspection by Date <br /> d\ional Comments: <br /> ❑ Stk 466-6781 ❑ 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. Box 2009, Stk., CA 95201 <br /> 3 <br /> FEE AMOUNT DUEIANiTREMITTED CASH RECEIVED BY DATE PERMIV NO. <br /> + EH 13-24(REV. <br /> ;.ri: EH 14-2e <br />