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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZETON 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. r <br /> E <br /> City Lot Size +` 'PM <br /> Job Address <br /> Owner's Name ° t—Iddress - Phone <br /> Address_ � �Llcense No. ;&4-?41 PhoE�� ` <br /> ContractorEaun <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL"LATION"O---;--""""SYSTEM REPAIR-Ej' """""' -OTHER..O• �- <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,_ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION` Z AGRICULTURE WELLY e OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WECL 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ,�❑ Industrials t ❑ Open Bottom, F ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> i <br /> ❑ Domestic/Private ElGravel Pack ElTracy -, Type of Casing ' Specifications I <br /> FI Public i ,,. 17 Other f.-1 Delta Depth of Grout Seal Type of Grout _ <br /> i { / - <br /> `I I Irrigation r --Approx. Depth t I Eastern Surface Seal lnoalled <br /> Repair W6,k`Done ❑ Type of Pump H.P. x State'Work Done <br /> f r i <br /> r � <br /> Well Destruction 4 } ❑ Wel! Diameter Sealing Material (tap 54') � <br /> Depth Filler Material (Below 501 -- <br /> f,,TYPE�OIFSEPTIC',WORK: NEW INSTALLATIO REPAIR/ADDITION l I DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> . .•Y+ available within 200 feet.) <br /> i <br /> Installation will serve: Resi nce Commercial ther Q(1 <br /> 'Number of living.units: Number of bedro ms J <br /> ,ChpractefIof soil to a depth of 3 feet: Water table depth <br /> SEP-TK;-TANK ❑ Type/Mfg Capacity_ *dd No. Compartments <br /> ' PKG.-TREATMENT PLT. F1Method of Disposal <br />' } Distance to nearest: Well .. Foundation Property Line <br /> LEACHING UNE -fir LI No; & Length of lines. . '� Total length/size <br /> j Z 40 <br /> FILTER BED ❑—+-Dista cn a to nearest: :Well�07 Foundation Property Line <br /> SEEPAGE PITS Depth _'JI.ss" Size r Number <br /> SUMPS ;1 Ll . Distance to nearest: well tf'" Foundation r B r Property Line. r <br /> 1 DISPOSAL PONDS rl❑ 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 /> 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'Califomia."Contractor's hiring of 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." y` <br /> 1 The appli nt-mu Il for re spections ompl�te drawing on reverse side.. ^gyp <br /> T <br /> /�i/ •-�1 Date: �,f Co <br /> Signed X <br /> s FOR DEPARTMENT USE ONLY w <br /> Acca ted b Date Area <br /> ,Application p y <br /> Pi or Grout inspection by Date T Final Inspection by Dat' <br /> Additional Comments: x <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copi6s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �r J1 <br /> FEE r AMOUNT.DUE AMOUNT REMITTED CK RECEIVED BY DATE PERM17'NO. <br /> INFO' <br /> � r <br /> +.EH 13-24(REV.1/x 5) <br /> EH 14-26 <br /> 1 <br />