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APPLICATION FOR PERMIT ! <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. <br /> Job Address Cit Lot Size 7V CGeA4U PM <br /> Owner's Name Address [f�t�y[p /Vi J� Phone <br /> No- <br /> TYPE <br /> _ I <br /> Contrac r/; ` , LC Address License N <br /> i <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> -DISTANCE,TO'NEAREST:`SEPTIC TANK' ' . ­ ":SEWER LINES 'DISPOSAL FLD. 4 }PROP.~LINE <br /> FOUNDATION AGRICULTURE WELL.. ,OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA'S CONSTRUCTION SPECIFICATIONS <br /> .1;1-Industrial---------❑ Open 136ttom`F—Mantec7a " - Dia-of'Well Excavation 2 Dia. fo Well Casing <br /> ❑ Domestic/Private ❑ Gravel_Pack ❑ Tracy `. .,I"`t Type of Casing Specifications m <br /> EJ Public El Other � �- Ll Delta t epth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by 'i <br /> Repair Work Done ❑ Type of Pump H.P. (N :> State Work Done <br /> O; <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 i a' <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 j ,.._;,t ( 'available within 200 feet.) <br /> Installation will serve: Residence. Commercial4ti. f jOther """-�1�_ <br /> 3 <br /> Number of living units: Number o room , f <br /> Character of soil to a depth of 3 feet± rl Water table depth ® f i <br /> SEPTIC TANK Type/Mfg Capacity ®v No. Compartments <br /> PKG. TREATMENT PLT. ❑ f.__ Method of`Disposal <br /> Distance to nearest: Well Foundation ��Property Line` <br /> LEACHING LINE LINO. & Length of lines � Totallength/size Q kg <br /> � <br /> � p <br /> FILTER BED ❑ Distance to nearest: Well _ Foundation W� � Property Line, <br /> s <br /> SEEPAGE PITS I!a' Depth Size Number "x:- . <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line _._ <br /> DISPOSAL PONDS ❑ 1 <br /> 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 California."Contractors 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 peisons subject to workman's compensa- <br /> tion laws of California." -* e <br /> The applicant m s call for al r uire inspections. Complete drawing on revers siq&,, r <br /> 4 <br /> Signed X Title: Date: 4J <br /> j <br /> FOR DEPARTMENT USE ONLY f <br /> Application Accepted by Date -74 Area <br /> Pit or Grout Inspection by i Date Final Inspection by Dater <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,'Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT EMITTED CASH RECEIVED BY DATE PERMIT'NO. 1 <br /> + EH 1324 IREV.}/ft 51 �®�J 2�) -1 <br /> Ll <br /> EH 14-28 ` <br />