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tu APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA { <br /> I. <br /> Telephone (209) 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 /> Job Address _-. _ City Lot Size J����� PM <br /> Owner's Name Il f Address <br /> hone <br /> Contractor 6 Address Ivvdtnie No. Qz!e�o Phone 0 <br /> TYPE OF WELL/PUMP: NEW WELL X WELL REPLACEMENT ❑ DESTRUCTION 171 <br /> 41 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ t <br /> T : . a. <br /> DISTANCE TO NEAREST: SEPTIC TANK -.-._(1Q�� SEWER LINES' "`DISPOSAL FLo•_.Q�`e_nbP, LINE- <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS n <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> KI Domestic/Private JKGravel Pack ❑ Tracy Type of Casing c, Specifications <br /> t_1 Public ❑ Other R Delta Depth of Grout Seal Type of Grout f <br /> I I Irrigation —'Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet.! <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: I Number of bedrooms <br /> Character of soil to a depth of�3 feet: K Water table depth <br /> SEPTIC,TANK ❑ - Type/Mfg Capacity � <br /> _ PKG. TREATMENT PLT. ❑ �9�1`c13�� <br /> Distance to nearest: Well Foundation <br /> m <br /> p�OpePtye 9` <br /> -'t <br /> LEACHING LINE ❑ N�. & Len th of lineslength/size' k,.i•�t <br /> g Total <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 03A <br /> T SEEPAGE PITS I I Depth Size Number JLN <br /> SUMPS 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. <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: "I certify that in the performance of the work for which this permit is issued, l shall employ persons subject to workman's compensa- <br /> tion la of C ifornia." r. <br /> li <br /> The .pplican ust call fpr all requ'a inspections. omplete drawing v rse si <br /> Signed X Title: <br /> Date: — <br /> I1 EPA TN,%NT USE ONLY <br /> Application Accepted by ++! 2 Dat --fid`Area <br /> Pit o Grout nspection by,4 a -- / Date `t Y S- Final Inspection by e. <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi .369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> Yi � <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO /// CASH RECEIVED <br /> +EH 14-2gIREV.1iK51 uF �� U/ �� J/ <br />