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4/x , <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> F Telephone 12091 466-6781 <br /> rPERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> K ' <br /> t <br /> (Complete in Triplicate) <br /> 1 . <br /> Application is hereby made to the San Joaquin Locale 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 weii/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f <br /> -3q.1I City <br /> Lot Size PM <br /> Job Address <br /> f � <br /> Owner's Name rens .lx/.ad� - Phone <br /> op <br /> s r', fJ <br /> + AddressPhone <br /> Contractor License NI/A41 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT © DESTRUCTION ❑ 1 <br /> PUMP INSTALLATION © SYSTEM REPAIR I❑ OTHER ❑ <br /> DISTANCE TO"NEAREST: •SEPTIC TANK ►� __"-' ="` SEWER tINES._ DISPOSAL-EL'D'" ,"--PROP_.-LI_NE � F <br /> yy FOUNDATION AGRICULTURE WELL A OTHER WELL PITS/SUMPS <br /> INTENDED'USE TYPE OF'` YELL PROBLEM AREA _CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial �❑ Open Bottom. ❑ Manteca Dia. of Well Excavation Dia- of Well Casing , <br /> Domestic/Private ❑ Gravel Pack ._ ❑ Tracy- Type of Casing Specifications <br /> FI Publlc ❑ Other ; ❑ Delta Depth of Grout Seal Type of Grout <br /> a <br /> I l;Irrilj tion _._Approxi De th l 1 Eastern ._ Surface Seal Installed by - <br /> Repair Work Done I- Type of,Pumpp _ H.P. -., State Work Done — I <br /> Well Destruction ❑ Well Diameter Sealing Material Itop-5011 <br /> Depth'" Filler Material (Below 501N <br /> TYPE-OF. SFPTIC WORK: NEW..INSTALLATION tl REPAIR/ADDITION I i DESTRUCTION 111No septic system permitted if public sewer.is <br /> available within 200 feet.) J <br /> Installation will serve: Residence X11 Commercial— Other <br /> Number of living units: Number of bedrooms f or <br /> Character of soil to a depth of 3 feet:I I . Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ( <br /> PKG. TREATMENT PLT- Method of Disposal <br /> ED - � _ <br /> Distance to nearest: Well Foundation '.Property.Line <br /> s 1 - <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> fi <br /> SEEPAGE PITS I I Depth ° Size Number <br /> SUMP5 - L7 Distance to nearest: WeFii <br /> ll undation Property Line_. o <br /> DISPOSAL PONDS ❑ t <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. r <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 tc become subject to workman's compensation laws of California." Contractor's hiring or 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." F <br /> t 1 <br /> The applicant t call or all required inspection . Complete dr//awing on reverse side. <br /> Signed X Ffttle: Date: <br /> F R RE RTMENT USE ONLY : <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection byt. Date 2n:3 1- <br /> ei <br /> Additional Comments: ;'t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Servvis 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTER, CASH CK V RECEIVED BY DATE PERMIT'No. <br /> INFO <br /> EH 13-24(REV.1/n 51 s <br /> ei <br /> f EH 14-2e <br />