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APPLICATION FOR PERMIT <br /> � <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Cift <br /> 1601 E. HAZELTON 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 arid?or install the work herein described.This appllcatiori 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. <br /> r:J Erlt Or) s t O " tr.4•, <br /> f CityLot Size - PM <br /> Job Address <br /> Owner's Name <br /> 6 Mai _�Addres ��. Q�— Phone _— <br /> .+. <br /> �-� - _ Phone <br /> Contractor's Nam _ `�,Licens_e N_ o. <br /> Contractor's NaZ _ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ :SYSTEM REPAIR ❑ OTHER. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r f DISPOSAL FLD. PROP. LINE :' <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> -r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial F] Open Bottom 1J Manteca Dia. of Well Excavation _— Dia. of Well Casing <br /> ElIndustrial <br /> ' ❑ Domestic/Private, i❑ Gravel Pack ❑ Type YPof Casing__ 9 Specifications <br /> ❑ Public Other ❑ Delta .�- Depth of Grout Seal _ Type of Grout <br /> t 9 I -- <br /> ❑ Irrigation, --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H P State Work Done <br /> Well Destruction El ll Sealing Material {top 50'1 <br /> _ Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> „ I vailable within 200 feet.l <br /> Installation will serve: Residence— Commercial,_.Other f <br /> I Number of living units: Number of bedrooms e <br /> Character of soil to a depth of 3 feet: Water table depth <br /> tNo. Compartments — 1 <br /> SEPTIC TANK ElType/Mfg `• Capacity L+ <br /> Method of Disposal <br /> PKG. TREATMENT PLT. El } <br /> Distance to nearest! Well .Foul dation. Property Line <br /> a . <br /> .�' Total length/size <br /> LEACHING LINE ID No. & Length of lines 9. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; <br /> }r.3' <br /> SEEPAGE PITS ❑ Depth Size <br /> i` Number <br /> SUMPS D Distance to nearest: Well Foundation Property Line <br /> . ty _ <br /> DISPOSAL PONDS ❑ <br /> l I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county Ordirrances,'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 suc nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"! ertify that in the performance of the work for which this permit is issued, I shall employ persons subj6ctto workman's compensa- <br /> tion laws of Califo 'a ' u <br /> The ap licant s I for all required i ns. Com to rawing ide. <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by date Area <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by = _ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca ffi3 7104 EI Tracy 83x6385 <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 CK RECEIVED BY DATE. PERMIT'NO. <br /> INFO CASH ^�'`{� <br /> + EH 33.24{REV.10183? ��. T 3 55--A 7A <br /> EH 14-26 <br />