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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4 <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 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. <br /> j <br /> Al City Lot Sire ' PM <br /> Job Address i <br /> t'. <br /> ll�� hti Address �/ � r+Phane <br /> Owner's Name - 4. <br /> � � Address } �� License No. - <br /> Phone <br /> Contractor <br /> WELL•REPLAGEMENT. ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW-WELL--9 . ,'-,�. <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE S" _:- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED_USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca pia. of Well Excavation 11` <br /> Type of Casing Specifications �\ <br /> ❑ Domestic/Private ❑ Gravel Pack El Tracy --t YP g E -Type of Grout - <br /> 1`1 Public ❑ Other ❑ Delta i Depth of Grout Seal <br /> I i Irrigation �__Approx. Depth 1 1 Eastern Surface Seal Installed by <br /> H P 4 State Work Done_ <br /> Repair Work Done- ❑ Type of Pump . <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l l REPAIR/ADDITION l i DESTRUCTION available e w thin 200 feet.)ied if public sewer is <br /> F <br /> Installation will serve: Residence= Commercial_ Other <br /> Number of living units: � Number of bedrooms y _ �. _,• �„!, <br /> T "-" Water table depth <br /> Character of soil to a depth of,3 feet: <br />! SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> A ;a i LL <br /> LEACHING LINE Ll No. & Length of lines Total length/size <br /> I tPro Property Line <br /> FILTER BED{ ❑ Distance to nearest: Well Foundation P V <br /> SEEPAGE PITS 11' Depth Size Number <br /> SUMPS Ll Distance'to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 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. <br /> 6 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 /> f 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 /> I The applicant must call for all required inspections. Complete drawing on reverse side.' <br /> C <br /> Signed X <br /> Title: Date: <br /> .FOR DEPARTMENT USE ONLY . <br /> �� 1 <br /> Application Accepted by dateArea <br /> Pit or Grout Inspection byDate Final Inspection by Date <br /> A ��� v'�, 6-aa-?o 9fAdditional Comments: <br /> Ll Stk 466 6781 ❑ Lodi 369-3621 ❑ Manteca 623-7 ❑ Tracy 835-6385 i <br /> I <br /> Applicant- Return all copies to: Environmental Health.Permit/Services 1601Z Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ffF;AMj0UNjT.. C RECEIVED BY DATE PERMIT'NO. <br /> UE AMOUNT REMITTED A <br /> � ' <br /> I . EH 13-24(H EV.V IM 57 S <br /> EH 16-2e <br />