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7 ,.- <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> I 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> r <br /> Job Address _._.. City ize ZC) 41-V `PM <br /> r <br /> Owner's Name ` . Aress . Phone <br /> I <br /> Contractor ' Address Lgicense No.��f "�K.Pr Phone <br /> TYPE OF WELL PUMP: NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .—'PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> AN <br /> DISTANCE TO NEAREST: SEPTIC TK. SEWER LINES DISPOSAL.FLD. PROP. LINE <br /> ' FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL '� 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 /> i`1 Public r `+A ❑ Other # (Z Delta Depth of 675_L Seal�""'"`_ _ Type of Grout <br /> I I Irrigation fR _-Approx. Depth" l I Eastern., Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump ' , 1H.P. State Work Done• <br /> Well Destruction t ❑ Well Diameter Sealing Nlaterial-(top 50') <br /> Depth Filter Material Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 i REPAIR/ADDITION DESTRUCTION { I (No septic system permitted if public sewer is J <br /> _ r within 200-feet,) <br /> i <br /> Installation will serve Residence <br /> YCommercial ther i <br /> Number of living unim,-_-Z� Number of bedrooms 3 ! <br /> Character of soil to a depth'o 'feat:, <br /> f 3Water table'deQth i <br /> E SEPTIC TANK ❑, Type/Mfg <br /> Capacity__R,— No. Compartments <br /> j PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance:to nearest: Well Foundation Property,Line <br /> t r <br /> LEACHING LINE 0 i o. & Len h Y Total length/size <br /> I <br /> 9t of lines r <br /> FILTER BED LJ Distance to nearest: Well c''Ts r Foundation, le Property Line <br /> k <br /> SEEPAGE PITS I i Depth fi Y Size t T 'S t ! Number <br /> SUMPS. , .ate Ll Distance to nearest: Well Foundation Property Line'- <br /> DISPOSAL PONDS,,; ❑ <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. _. F <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, l shall not <br /> employ any person in such manner as to 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." <br /> The applicant must for all requir i pectin Complete drawing on reverse side. <br /> Signed .Title: Date: <br /> FOR 0 RTMENT SE ONLY Q` <br /> Application Accepted by Date -A�ea v <br /> Pit or Grout Inspection by ' Date Final Inspection by Date� 1a <br /> _ m Additional.Comlrents: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 •u -- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> +.EH 3-24 EH 14.2[3(REV.F n 5) �7 )� 3 .� se-1,41 8 Eq -`a <br />