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APPLICATION FOR PERMIT <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) <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 i� <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.. / <br /> Job Address __4L YefV17 City fielan Lot Size PM <br /> Owner's Name a i -c •i Q!\ Address J Y✓1 Phone <br /> Contractor ,� �� �• _� AAddress � � <br /> License Phone <br /> No �S�[� <br /> t <br /> TYPE OF WELL/PUMP: I! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP-.INSTALLATION,0 _ -. .SYSTEM REPAIR_©_,,,,, OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑iGravel Pack ElTracy, Type of Casing Specifications <br /> ;# i'i Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout_ <br /> I I Irrigation .1I;-Approx. Depth I'] Eastern Surface Seal Installed by _ <br /> ft Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 v1 <br /> Depth Filler Material (Below 50') _ J <br /> 3 TYPE OF SEPTIC WORK: NEW INSTALLATION- REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is t <br /> ' ` ' available within 200 feet.) <br /> Installation will serve: Res!enceCommercial_ Other l n <br /> Number of living units: Number of bedrooms V <br /> Character of soil to a depthl�of 3 feet: <cd 0--o Water table depth <br /> SEPTIC TANKListance <br /> Type/Mfg fP.l Gr711G('d4-G Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> to nearest: Well 11 Foundation !0 Property Line CCl <br /> LEACHING LINECyNo. & Length of lines Total length/size <br /> FILTER BED Ll Distance to nearest: Well J—y`Ef µFoundation • J Property Line 1 <br /> k SEEPAGE_ PITS I/r(Depth mm [ Size _. ._� Number <br /> SUMPS Ll Distance to,n­eatest,.­--WeII,4 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 Di§trict. <br /> Home owner or licensed ageni'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 t.4become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certif y that in the performance of the work for which this permit is issued, I shall employ parsons subject to work n's compensa- <br /> tion laws of California." iPI <br /> - - on reverse side. <br /> ...g <br /> The applicant must-call for Ire wired inspections. Complete drawing <br /> t Signed X��4 1.1%LYiI.�[/ Titla:r ✓a G+'� Date: <br /> F I TMENT USE ONLY —Q <br /> f Application Accepted by Date Area <br /> i <br /> Pit or Grout Inspection by �I� Date .Final Inspection by19 Pat <br /> Additional 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, Sik., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> . INFO - ryJ¢ CASH , <br /> ...+�•-EH 13.24{REV i i n 51 �. J� <br /> EH 1428 � <br /> I S jam, <br />