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APPLICATION FOR PERMIT RECEIVED <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Ug� <br /> Telephone (209) 466-6781 ENVIRONMENTAL HEALTH <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED PERMIT/SERVICES <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. 1B62 for wewpump and the Rules and Regulations of the San Joaquin Ir <br /> Local Health District. <br /> eLot Size PM i <br /> Job Address _ _ City <br /> f <br /> Address Phone <br /> Owner's Name <br /> Contractor �AIE <br /> fit�e�Lf L Address <br /> License No.a r��Phone JL61 W(,46�7gq:? <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> 171 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type of CasingSpecifications <br /> w mestic/Private C7 Gravel Pack ❑ Tracy yp YP <br /> T e of Grout <br /> f'1 Public ! I Other n Delta Depth of Grout Seal <br /> I i Irrigation __,_Approx. Deptht II Eastern Surface Seal Installed by i <br /> Repair Work Done ❑ Type of Pump s H. State Work Done <br /> Well Destruction ❑ Well Diameter _Zo 9V Sealing Material Itop 50'1 <br /> Depth_I6�,o Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'l REPAIWADDITION l I DESTRUCTION I I iNailabo eptic system <br /> m Permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS l I Depth Size Number <br /> - -� <br /> SS-SUMPS 11 Distance `Pro a Line" . —-- -'to'nearesi: Well Foundation" �"��` P rtY <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 Di§trict. <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 /> f certifiesthe folio Ing: "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 Cal forni .' <br /> The appli nt s call for all re it d inspect- s. Complete drawingside. <br /> ! Signed X Title: Date: <br /> �FDEPAgRTMNTUSE ONLY <br /> � U Area <br /> Application Accepted by Date 'Z <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-87$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 L1 Tracy 835-6385 <br /> i ermit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> Applicant- Return all copies to: Environmental Health P <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH CK Er <br /> DATE PERMIT N <br /> INFO �J <br /> 7 + EH 13-24(REV.I/M 61 �5- <br /> EH 1 4-28 <br />