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,C' - <br /> APPLICATION FOR PERMIT <br /> k 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 <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sari 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." <br /> Job Address City of Size a _ 4M <br /> Owner's Name Address Phone <br /> Contractor's Name License No. rt' Phone <br /> /�4 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT'❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> ° FOUNDATION _ ti AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom L] Manteca Dia. of Well Excavation - Dia.,-of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy°-+ { Type of Casing f Specifecations <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed,by .+ <br /> Repair Work Done ❑ Type of Pump H.P. Y State Work Done 'fes <br /> I Well Destruction ❑ Well Diameter Sealing Npierial_(top 501 - <br /> h Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK.: NEW INSTALLATION ,REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> i [ available within 200 feet.} <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of b9ofoomi d <br /> Character of soil to a depth of 3 feet: 0.1 Water table depth <br /> SEPTIC TANK Type/Mfg + i Capacity No. Compartments <br /> PKG. TREATMENT PLT. F1 t c Method of DiVgsai <br /> r g <br /> Distance to nearest: Well Wur�tion Ag Property Line <br /> LEACHING LINE No. & Length of lines Tgtal length/size 17 I <br /> FILTER BED Ll Distance to nearest: Well l4dfiNnn Property Line <br /> I 17 r <br /> SEEPAGE PITS Depth ( Size Number <br /> SUMPS CI Distance to nearest: well at- ation <br /> El <br /> Property Line <br /> DISPOSAL PONDS ,S t — <br /> 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 permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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." i <br /> The applicant u for I regdrr-ecNnspections. Co late drawing on pev{eE rse side. ; <br /> Signed Title: �1 ir� Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml - 1 .❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- ;J rf'jv�4 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK 4 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH13-24(REV.10181) ' - <br /> EH 1428 <br />