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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 � �� LID^ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �s 1 jNSTP3C r <br /> (Complete in Triplicate) ( � <br /> i <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. 177 y� } <br /> Job Address = ) / City � 1 'ta Lot Size PM <br /> Owner's Name r '31rY WoKM Address PhoneAg <br /> E 1 r <br /> Contractor's Name�+�/P �� License No. IV 1 Q ' Phone ,2 V <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ NDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ i OTHER ❑ < <br /> DISTANCE TO NEAREST: SEPTIC.TANK SEWER LINES DISPOSAL FLD. `' PROP. LINE q <br /> FOUNDATION F AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF_WELL_PROBLEM AREACONSTRUCTION SPECIFICATIONS <br /> El Industrial "..�,-.'�.,--t E Open Bottom ❑ Manteca T�Dia. of Well Excavation Dia. of Well Casing <br /> k Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications -21 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout J <br /> ❑ Irrigation ---Approx. Dep h ❑ Eastern 'Surface Seal Installed by <br /> Repair Work Done 1K Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ' <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEIN INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> �availahle,withirt�00_feet-lam-- . <br /> '(0- <br /> Installation will serve: Residence_ Commercial_ Other 5 <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 Capacity No. Compartments <br /> 1>4 KG. TREATMENT PLT. ❑,L • ' ...= Method of Disposal <br /> Distance to nearest: Well Foundation '� Property Line <br /> LEACHING LINE •❑'' No. &,Length of•lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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. f <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 /> The applic ust II for al r ui a inspections. Complete drawing bn reverse side. <br /> Signed Title: Date: <br /> F FOR DEPARTMENT USE ONLY <br /> g Application Accepted by Date '{,Area, (Z <br /> Pit or Grout Inspection by Date ` Final Inspection by VP- Date , r <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 { Z <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 T Pr <br /> 4 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. C X <br /> + EK 1&24(REV.10183h �1, <br /> EH 14 <br /> ff / ] 1 <br />