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APPLICATION'�FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> [� <br /> H <br /> 1601 <br /> E. AZE.T ON AVE.,-STOCKTON, CA <br /> eu f� Telephone (209) 466-6781. <br /> PERMIT EXPIRES 1 YEAR FROM-DATE ISSUED .. <br /> rl.,j- s t.(Complete in Triplicate) t <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 L <br /> Job Address (, Cit <br /> y t Size pm <br /> 1 <br /> "Owner's Name =Address Phone <br /> Contractor Address �dt icense No.�C�Phone �\ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION❑ T- -SYSTEM REPAIR l�' I{ <br /> OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FED. PROP. LINE <br /> FOUNDATION _ k. AGRICULTURE WELL OTHER WELL] PITS/SUMPS <br /> INTENDED USE TYPE OF WELL t PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial [I Open Bottom ❑ Manteca Dia. of Well Excavation r��#i Dia. of Well Casing <br /> Domestic/Private EJ Gravel Pack (D Tracy Type of Casing `"� Specifications <br /> Public ❑ Other <br /> ❑ IS Depth of Grout Seal f Type of Grout i <br /> ❑ Irrigation <br /> ---Approx. Depth,' Easfern S ace Seal Installed by <br /> Repair Work Done k Type of Pump H.P. State Work,Done <br /> 'Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material lBelow 50'I I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑,1N6'septic system permitted if public sewer is <br /> ' availa6le within 200 feet.) <br /> Installation will serve: Residence Commercial; Other" <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity �r " 1N0. Compartments I <br /> PKG. TREATMENT PLT. ❑ J l € <br /> ✓' <br /> r,Method of Disposal <br /> Distance to nearest: Well FoundationPropeiIf i Line <br /> i � <br /> LEACHING LINE ❑ No. & Length of lines f r.., Total length/size <br /> FILTER BED ❑ Distance to nearest:- Well - Foundation ;r <br /> • - '' "`Property Line <br /> t <br /> SEEPAGE PITS ❑ Depth h Size Number <br /> SUMPS ❑ Distance to nearest: Well - Foondation }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 SaniJoaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Disttict. �'! <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."Contractor's hiring or sub-contracting signature <br /> certifies the following: "t certify that in the performance of the work for which this permit is issued, I shall empioy persons subject-to workman's compense- <br /> iion laws of California." <br /> �t� f: ., <br /> The appli u call for all r red ins ctions. mple`te drawing on eve�se side.�t l <br /> g <br /> Si ned X Title: ���4 pate: <br /> 14< <br /> FOR DEPARTMENT USE ONLY x <br /> Application Accepted by <br /> Data r Are I <br /> Pit-or Grout Inspection bDate Final Inspection by Date O <br /> Additional Comments: J <br /> 13Stk 466-6781 11Lodi 369-3621 Y ❑ Manteca,,823-7104 ❑ Tracy 835-6385 1 <br /> Applicant- Return all copies to: Environmental Health%P,errni0Services 1601 E.,Hazelton Ave., P.O. Box 2009, StkL CA"95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK i...- - RECEIVED BY DATE PERMIT NO. <br /> INFO CASK r <br /> +'EH t3-24{REV.1 i a sl `/� }]` 16 <br /> EH 14-28 J 5: F7 �.�/' <br />