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APPLICATION FOR PERMIT <br /> I` <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I9 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone 52091 468-6781 <br /> B PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> f <br /> I (Complete in Triplicate) <br /> Application is hemby 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 <br /> District. <br /> r f �t <br /> Job Address !ZL! CityLot Size PM <br /> /� � <br /> Owner's Name t I' -I ddress Il 0 -CJI Phone 9� ' <br /> I 'ii' � - <br /> Contracto Address .;Std License No. Q C� Phone r s <br /> d TYPE OF WELL/PUMP: NEW WELL ❑ W_ ELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t I PUMP INSTALLATION ❑ '" " ' SYSTEM REPAIR El .OTHER ❑ �.- <br /> I DISTANCEiTO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL S/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT IFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack E] Trac Type of Casing Specifications <br /> 1-1 Public �P F1 Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _A epth I I Eastern Surface Seal Installed by - <br /> i Repair Work Doneype of Pump H.P. State Work Done _ <br /> t Well Destruction LJWell Diameter Sealing Material (top 50') <br /> II Depth Filler Material (Below 501 <br /> > TYPE OF SEPTIC WORK: NEW INSTALLATION l-] REPAIR IADDITION IJ DESTRUCTION (No septic system permitted if public sewer is <br /> f <br /> 11 available within 200 feetJ <br /> Ip <br /> r Installation will serve: Residence f Commercial_ Other <br /> Number Iof living units: Number of bedrooms r <br /> F Charactehi of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> 4 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> y k <br /> Distance to nearest: Well f Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> + FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 4 ' <br /> SEEPAGE'4PITS I'] Depth IA Size Number <br /> t SUMPS li ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared,this application and that the wwork'will'be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "1 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:-1 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 applicant must ctions. Complete drawing on reverse side. <br /> Signed X I� Title: �-� Date: a V <br /> } FOR DEPARTMENT USE ONLY <br /> �iA �j <br /> l Application Accepted by Date _ I Area <br /> I <br /> Pit or Grout Inspection by to Final I p tion by Date <br /> -$ TQX4 <br /> Additional Comments: 1 ' <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ TraK 835-6385 <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 AMOUNT DUEAMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> I INFO CASH <br /> + EH13-24IFIEV.1/951 3` <br /> EH 14-26 I� - <br />