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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH-DISTRICT +$ <br /> 1601 E. HAZELTON AVE-, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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 /> t <br /> Local Health District. r7 <br /> fJG j1( , <br /> Job Address <br /> Q City CC� Lot Size �7 I I t✓ PM <br /> i4 <br /> x Owner's Name /t0 �1t� +Pdl/32 l Address f� r��� � JPhone <br /> ST <br /> 4 Address .. /�aa License No. Phone <br /> L TYPE OF WELL/PUMP;- ,NEW.WELL_C7WELL REPLACEMENT DERUCTION ❑ <br /> EST -.0 - a....,— <br /> PUMP INSTALLATION ❑ . SYSTEM REPAIR•❑ � ��OTHER ❑DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES • `� DISPOSALFPROP. LINE-"FOUNDATION ' AGRICULTURE-WELL- R-WELLPIT <br /> = H <br /> PS.- <br /> INTENDED.-USE TYPE OF-WELL PROBLEM AREAUCTION SPECIFICATIONS <br /> ❑ Industrial El Bottom F ❑ Monte Dia-. of;We�Excavation""-' Dia. 'o#Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> Fl Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ' 6\ <br /> i I Irrigation pprox. Depth I 1 Eastern h. Surface Seal installed by. 1 <br /> Repair Work Type of Pump H.P. State Work Done;'_ Y <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.11 REPAIR/.ADDIT4ON-I-_DESTRUCT40N- -iNo-septic-system-permitted if public sewer is � - <br /> vailable within 200 feet.) <br /> Installation will serve: Residence_ Commerciale Other <br /> Number of living units: Number of bedrooms r <br /> Character of soil to a depth of 3 feet- Water table depth` <br /> SEPTIC TANK Type/Mfg i. Capacity _ No. Compartment$ <br /> PKG, TREATMENT PLT. ❑ .„ F . l r Method of Disposal <br /> Distance to neatest: Well Foundation,'^ Property;Line <br /> T <br /> „�. f• <br /> LEACHING LINE ❑ No. & Length of tines `r Total length/size <br /> FILTER BED 1-1Distancelto nearesta'Well Foundation Property Line <br /> ` 'J • 'ir t .� . <br /> t SEEPAGE PITS Depth ° Size Number <br /> SUMPS 11 Distance-to neatest:i Well Foundation Property Line <br /> DISPOSAL PONDS ❑ `i { <br /> I hereby certify that I have prepared this applicaticin 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 foilowing: "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 tobecome subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies Ih'e following: "i certify that in the performance of the work for which this permit is issued,.l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must all ire - coons. Complete drawing on reverse side. <br /> XSigned X Title: �'� Date: ` <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted-by Date �! Area <br /> Pit or Grout Inspection b Date c w Final Inspection by Date <br /> Additional Comment 6 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ,❑ Tracy 835-6385 <br /> ,lkpplicant_ Return a I copies to: nvironmental He Ith Per it/ 16p1,E. FLeXelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED'' SR RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> �7 P <br /> t EH 13-24(REV.t/n sl 3�5 <br /> � /� 6 <br />