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APPLICATION FOR PERMIT ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ' w PERMIT EXPIRES 1 YEAR FROM DATE ISSUM <br /> b lCom`plete in Triplicate) d ; <br /> F xr. <br /> Application is hereby.made to the San Joaquin Local Health District for a permit to construct and <br /> install the work herein descrifil d:'This application is <br /> made in complianc' ;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 Distrr. p <br /> E t. t City a Lot Size est 069:1 PM <br /> tiJob Add_ s �. 01 <br /> Y F ' <br /> L : t: Phone ^d <br /> Owner's Name Address <br /> ! r; Address ' license No.�_.. Phone <br /> Contractor h , <br /> NEW WELL ❑ WELL REPLACEME ❑ DESTRUCTION ❑ <br /> TYPE OF WELLIPUMP: OTHER ❑ <br /> PUMP INSTALLATION 11SYSTEM R AIR L1 <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEW LINES . <br /> FOUNDATION AGR1.0 TURF L OTHER WELL PiTSlSUMPS <br /> ,INTENDED USE TYPE OF WELL PROBLEM AREA", NSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> 0Industrial ❑Open Bottom ❑ Manteca, ,• Di �f Well Excavation- V <br /> Specifications, <br /> \ <br /> ❑ DomesticIPrivate ' ❑ Gravel Pack ❑ Tracy Type Casing Tpe of Grout \ <br /> f 1 Public <br /> ❑ Other F1 Delta Depth of ut Seal <br /> :App(ox. Depth l l.E tern Surface Seal In liedby <br /> f i linga ion — <br /> Repair Work Done ❑', .Type of Pump H.P. State Work Done <br /> -'-.Sealing Material (top 50') <br /> r•Well Destruction ❑: Well Diameter 9 _ ` <br /> 1 Filler Material (Below 50'1 ' <br /> i .t Depth <br /> .•TYPE OF SEPTIC WORK: NEW INSTACLATlON I:I REPAIR/ADDITION DESTRUCTION (,l (No septic system permitted it public sewer is <br /> 1 , % available within 200 feet.) <br /> i f - <br /> :' Installation will serve: Residence Commercial Other j- <br /> ,'! <br /> .Number of living units: � Number of bedrooms_'•�_,,,,r, �• w .•'� � � 4 t <br /> * a Character of soil to.a depth of 3 feet: Water table depth <br /> � t <br /> SEPTIC TANK ❑ TYPe1Mfg <br /> Capacity. No. Compartments <br /> PKG.-TREATMENT.PLT. ❑ Method of Disposal <br /> -Distance to nearest: Well -•�' 'Foundatiori Property.Line - <br /> ' LEACHING LINE ❑ ' Na. & Length of lines,. <br /> Total length/size <br /> 0 S <br /> FILTER'BED - ❑ " Distance to nearest: Well 1 n Or_ Foundation . Property Line <br /> Size Number ' <br /> SEEPAGE PITS l 1 Depth <br /> SUMPS Ll • Distance to.nearest: Weil Foundation Property Line <br /> r 1 DISPOSAL.PONDS ❑ <br /> `I hereby certify That l have prepared this application and that'the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I i 1 rules and`Pbgulations of the San Joaquin Local Health District. <br /> Home owner orlicensed 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 /> 'A' t... . <br /> employ any person in such manner as to become subject to workman`s compensation laws of California." Contractor's hiring c sub contracting signature <br /> certifies ihefollaWilig: "I certify that in the performance of the work for which this permit is issued, I shall'temploy persons subject to workman's compensa <br /> tion laws`df California.". <br /> The applicant must call for all requi nspections. Complete drawing an reverse side. <br /> d X Title: e' <br /> kJSE-ONLY <br /> "A Date� : Area <br /> Application Accepted by <br /> Pit or Grout Inspection by Date Final Mspection by <br /> - '-Date � <br /> Additional Comments: <br /> ❑ Stk 466-6781' Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> Y01EUNTD WEE CASH <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> a.EH 13-24 IREV. As) <br /> EH 1426 <br />