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APPLICATION FOR PERMIT <br /> Rt� <br /> n2vASAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ® _ <br /> Telephone (209) 466-6781 AUG 3 1 CMM <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED N1iiR0 ti SAI HEALTH <br /> (Complete in Triplicate) �������-�.f,������ � <br /> made <br /> Appliin cation 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 /> Local Health District. mcompliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welflpup and the Rules and Regulations of the San Joaquin <br /> Job Address � � Q �� <br /> City - Lot Size PM <br /> Owner's Name - Address <br /> `��, Phone r <br /> Contra <br /> ctor�l _Address (d <br /> r License No 4113F62-- Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES } <br /> DISPOSAL FLD. PROP. LINE 1 <br /> FOUNDATION AGRICULTURE WELLi <br /> PITS/SUMPS <br /> INTENDED USE OTHER WELL TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man~teca Dia. of Well Excavation <br /> _ Domestic/Private ❑ Gravel PackDia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> f`l Public Cl OtherF Delta Depth of Grout Sea! Specifications — <br /> I I Irrigation —Approx.�t Depth l I Eastern J Surface Seal Installed by Type of Grout—_ <br /> Repair Work Done & Type of Pump /1 c-+- H P _ <br /> — State Work Done <br /> Well Destruction ❑ Weil Diameter <br /> Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') + <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION f 11( DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> .--installation will serve: Residence— Commercial _ Other � available within 200 feet.) <br /> )11�j�` Number of living units: _ Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> PKG..TREA-TMENT PLT. LJ <br /> ❑ Type/Mfg Capacity — No. Compartments <br /> � - <br /> t Method of Disposal <br /> Distance to nearest: Well Foundation <br /> .- Property Line <br /> LEACHING-L-INE ❑ No. & Length of lines <br /> BED Total length/size <br /> FILTER <br /> . . ❑ Distance to nearest: Wel! Foundation <br /> Property Line <br /> SEEPAGE PIT! 4i I pepth Size <br /> SUMPSNumber <br /> L-f Distance'to nearest: Well Foundation <br /> t DISPOSAL PON Property�. - , Property Line <br /> I hereby certify that I have prepared this ap ication 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 /> Horne 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 athe ny pelowingrson in such manner as to becom6-subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies <br /> laws of Clali orn a,•I certify that in the performance of the work or which this permit is issued, I steall employ persons subject to workman's compensa- t <br /> The applicant mu alk r all requirgd inspections. Complete drawing on reverse side. J <br /> Signed X <br /> — Title: �Q <br /> Date: <br /> DEPARTMENT USE ONLY <br /> j p216 <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Additional Comments: Final Inspection by Q <br /> Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED a- 1 CK <br /> INFO CASH RECEIVED BY DATEHRM 'NO. <br /> +,EH 13-24 IREV.t i s 5) <br /> £H 14-28 A f�� 0 q � <br />