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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <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 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 __ � city/ -822!L Lot Size <br />9 <br />Owner's Name �+ �"�'� Address _ Phone <br />Contractor -AND <br />TYPE OF WELI;/ <br />DISTANCE TO <br />.INTENDED <br />7 Industrial <br />❑ Domestic/P <br />I'1 Public <br />I ` Irrigation <br />Repair Work C <br />Well Destructi <br />Address <br />License No.4 Phone <br />MP: NEW WELL L WELL. REPLACEMENT ❑ DESTRUCTION U <br />PUMP INSTALLATION ❑ SYSTEM REPAIR U OTHER ❑ <br />REST: SEPTIC TANK _ SEWER,LINES _ DISPOSAL FLD. PROP. LINE _ <br />FOUNDATION AGRICULTURE-WELC'— OTHER WELL _ PITSISUMPS <br />TYPE OF WELL <br />7 Open Bottom <br />Cl Gravel Pack <br />a <br />71 Other <br />_-Approx.Depth <br />Type of Pump <br />Well Diameter ._ <br />Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ' REPAIR/ADDITION I DESTRUCTION 1 1 (No septic system permitted it <br />available within 200 feet.) <br />public sewer is <br />f f 1 f <br />' M <br />installation whl .serve:. Residence e Commercial _—Other <br />1 <br />Number of living units: � ° Number of bedrooms � } i M r 1 1 <br />Character of foil to a depth of 3 feet: �_11 J Water table depth _ <br />CapacitQ No. Comnments <br />SEPTIC TANK � C Type/Mfg _.�� �_ __- Y� " <br />PKG. TREATMINT PLT. ❑ ' Method of Disposal <br />I Distance to nearest: Well 140 Foundation Property Line <br />LEACHING LINE f" No. &Length of Ines Tf1 _�� dotal length/sire FT <br />FILTER BED 9Distance to nearest.'`- ' WeU foundation. _� _ Propdity'Line " <br />SEEPAGE PITSli I 1 Depth ~_.> Srze Number �.. <br />SUMPS}i} l�'''Distance'td'ft'earesi: Well Pounda4i6Property Line <br />DISPOSAL POf DS ❑'�. Y_ } t. <br />1 hereby certify :that I have prepared this application and that the work will be done in accordance with San Joaquin coup_ ty ordinances, state laws, and <br />rules and regulations of the San Joaquin Local Health District. <br />Home owner ari licensed agent's signature certifies the following: "I certify that .in the performance of the work for Mich this permit is issued, I shall not <br />employ any per' n4"tich•rnanner-as•to become subject'1o'wo�kman's compensation laws of California." Contractor's hiring or suWcontracting signature <br />certifies the foltgwing: "I certify that in the performance of the work for.which this permit is issued, {shat{ employ persons subject to workman's compensa <br />tion laws of California." a »• , . `,v` <br />The applicant mustcal or all wired nspecfrons. Complete drawing on reverse side. <br />Signed X Title; _____ _--- Date:., <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by_ 6' ; ( _ . _� Date _ Area <br />Pit or Grout Inspection by Date Final Inspection by Jt — Date <br />j <br />Additional Comments: _ <br />C Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823=71104 Cr Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2049, Stk., CA 95201 <br />PROBLEM AREA <br />L Manteca <br />❑ Tracy <br />17 Delta <br />i I Eastern <br />CONSTRUCTION SPECIFICATIONS <br />Dia. of Well Excavation _..— <br />Type of Casing _ <br />Depth of Grout Seal _ <br />Surface'S"I Installed by .. <br />State,Work Done . <br />Sealing Material' (top 501 <br />Filler Material (Below 50') <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />PM <br />.. E14 13.24 (REV. r! H 5 <br />EH IA -26 <br />FEE AMOUNT. -DUE _._ <br />INFO.. _ <br />AMOUNT. REMIT -TED , -. -� H <br />.�..flECEIVED_ Y -..- �-..�-PATE----- -- <br />—.PERMIT NO— <br />01 <br />