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F APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR.FROM DATE ISSUED µ <br /> (Complete in Triplicate). <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/ortinstall the work herein described. <br /> made in compliance with San Joa uin County Ordinance No.549 for sewage or No. 1862 for well/ u <br /> Local Health District 4 � - g cubed. This application is <br /> �r}p and the Rules and.Regulations of the San Joaquin <br /> Job Address <br /> City .. E <. <br /> Lot Size PM <br /> Owner's Name -� <br /> �-�—� Address _ <br /> �- Phone <br /> Contractor � `� Address <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ` License No, <br /> PUMP INSTALLATION [ <br /> WELL REPLACEMENT ❑ DES7N LJRUCTlO <br /> DISTANCE TO NEAREST; SEPTIC TANK SYSTEM REPAIR [I OTHER EJ—� SEWER LINES �� DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL <br /> EJPROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial O Open Bottom ~ <br /> ❑ Manteca Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Dia. of Well Casing f <br /> T <br /> F-1Public C] Other Type of Casing <br /> ❑ Delta ---------Depth of Grout Seal <br /> Specifications <br /> 13 ) <br /> Irrigation ---Approx. Depth ❑ Eastern Type of Grout <br /> Repair Work Done [3 Type of Pump T � Surface Seal Installed by <br /> ./ —! % <br /> Weil Destruction L1Well Diameter H.P. --- State Work Done {� � <br /> Depth <br /> Sealing Material.(top.50'-) v <br /> , 3. <br /> Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REpAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> Installation will serve: ResidenceCommercial_ Other available within 200 feet.) <br /> �� <br /> Number of living uni ber of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK <br /> ❑ TypWater table depth <br /> e/Mfg t <br /> Capaciy' f r <br /> PKG. TREATMENT PLT. El to No. Compartments-.- <br /> ethod of Disposal_ <br /> Distance to nearest: Well <br /> ~ M <br /> Foundation Line <br /> LEACHING LINErf <br /> ❑ No.'& Length of lines <br /> FILTER BED ❑ Distance to nearest: WellTotal length/size <br /> Foundation Property Line <br /> SEEPAGE PITS © Depth <br /> SUMPS Size Number <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS 0 Foundation Property Line <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances state <br /> rules and regulations of the San Joaquin Local Health District. �^`� -E Tr+�} <br /> Home owner or licensed agent's signature certifies the following: laws, and <br /> employ any person in such manner as to become subject to workman's compensation laws Califo niche Cont actowork r which <br /> Jheipgr or sub contracting signature <br /> certifies the following: permit is issued, I shall not I! <br /> "!certify ihat'in the performance of the work for which-this-permit.is_issued, I shaft-employ persons subject to workman's com ansa- <br /> tion laws of California." <br /> The applicant m st call for all re wired ins P <br /> 4 inspections. Complete drawing an reverse side.4, <br /> Signe Z j <br /> Title: <br /> Date: f <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by D <br /> Date Area <br /> Pit or Grout Inspection by 7 � <br /> D7-� <br /> Final Inspection by Date �Additional Comments: <br /> 1:1Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104r <br /> Applicant- Return all copies to; Environmental Health Permit/Services 1601 EO Tracy X35-6380. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE { <br /> AMOUNT REMI ED CK RECEIVED BY; <br /> � CASH DATE <br />+ EH13-24fREV.t/nsJINFO PERMIT'NO.-�\ �' a <br /> EH 1428. V - /''�7 <br /> 'tet./ <br />