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- APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL .HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE. STOCKT <br /> ON, CA <br /> i u Telephone (209).466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> "; -• f¢'�j {Complete in Triplicate} ,.. j <br /> �rlictio�is hprdG'�ma a to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> aideg"dAkiplia'nce 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 /> l Health District. „ <br /> i•- <br /> Jab Address City Lot Size PM <br /> Owner's Name - <br /> Address �L .�? _ Phona <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT C1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.' OTHER ❑ <br /> -. <br /> DISTANCE TO NEAREST: SEPTIC TAN SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL. OTHER WELL PITS/SUMPS t y <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 J <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> � . <br /> ❑ Irrigation ��Approx. Depth �❑ Eastern Surface Seal Installed by <br /> 06 <br /> Repair Work Done Elr Type of Pump �� H:P. State Work Dane . <br /> Well Destruction ❑ Well Diameter roti Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION. ❑ DESTRUCTION 0 (No septic system permitted if public sewer is <br /> v�' r available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other t I - *j j j <br /> Number of living units: Number of bedrooms C- ' } <br /> Character of soil to a depth of 3 feet: F Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity- .- No. Compartments <br /> PKG. TREATMENT PLT. ❑ 4 <br /> } f Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> � t . <br /> LEACHING LINE ❑ No. & Length of lines ti k'T"TotaPlangth/size <br /> FILTER BED '❑ Distance to nearest: -Well Foundation <br /> Pro <br /> FILTER <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest:--.. Well f •--.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. <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 t <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 k <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 muse call for wired inspections. Complete drawing on re se side. <br /> Signed - Title:——`�'�'•:r�«- °Date: IJV" <br /> FOR DEPA MENT USE ONLY <br /> F <br /> Application Accepted by _ Date ��'__,k Area <br /> .Pit or Grout Inspection by Date Final Inspection by � Date 3 <br /> 'Additional Comments: <br /> ❑ Stk 466-6781 -❑ Lodi 369-3621 T ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> 7 <br /> INFO AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT"N0. ! <br /> + EH 13-24(REV.10183) �_ '+ ' "' '- '�' - .k <br /> EH 14-28 <br />