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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 4 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> w ' (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit t6—construct and/or install the work herein described. This application is <br /> made in compliance with San Joaquin County rdinance No.549 f r sewage No. 1862 for well/pump and the Rules and Regulations bf the San Joaquin <br /> Local Health District. <br /> -r- t - , <br /> i LAd C City Lot Size PM / <br /> 6 {- Address ; CL 44 �C�2LI fiD�� Phone <br /> Address License No. -Phone <br /> TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ElCTION El <br /> INSTALLATION El SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE { <br /> FOUNDATION AGRICULT ELL OTHER WELL PITS/SUMPS NJ <br /> INTENDED USE TYPE OF WELL PROBL REA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 11 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other r ❑ Delta Depth of Grout Seal Type of Grout 6611 �y <br /> ❑ Irrigation pro Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ pe of Pump H.P. State Work Done <br /> Well Destructi Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Mo septic system permitted if public sewer is <br /> available within 200 feet.] <br /> Installation will serve: Residence Y ..--Commercial_ yOther <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 /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Properfy Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line 4 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest. Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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."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." % - p <br /> The applicant must call for all required inspections. Complete drawing an reverse side. <br /> _ t - <br /> Signed Title: _ 0&)n Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DatArea <br /> 1 U <br /> Pit or Grout Inspection by � Date � Final Inspection by Data <br /> r e <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. box 2009, Stk., CA 95201 . <br /> FEE <br /> INFO AMOUNT DUE `� AMOUNT REMITTED S RECEIVED 9Y DATE PERMIT NO. <br /> + EH 13-241REV-i/a51 "n <br /> e EH 14426 -1 <br />