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APPLICATION FOR PERMIT ti <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heFeby 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 a 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. I I <br /> joh� Cite Lai Size I'M i <br /> Job Address <br /> ZY� ane <br /> Address <br /> Owner's Name <br /> License No..Phone_ <br /> Contractor Address <br /> TYPE OF WELLlPUMP. NEW WELL 17 WELL REPLACEMENT ❑ DESTRUCTION ❑ �;. <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR ❑ OTHER C3 <br /> SEWER LINES <br /> ��__ DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS._— <br /> ..-FOUNDATION ---- AGRICULTURE WELL.. . � t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> r <br /> Type of Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t yp Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> M Public Surface Seal installed by <br /> I 1 Irrigation —.Approx. Depth l I Eastern <br /> A H P 1 State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Weli.Destruction . F1Well Diameter <br /> Sealing Material (top 501 <br /> Depth T Filler Material JBelow 50') <br /> TYPE OF SEPTIC WOflK: NEW INSTALLATION I1 REPAIfl1ADDITION t 1 DESTRUCTION available rwit in 200 le or.No septic system ) <br /> if public sewer is <br /> Installation will serve: Residence Commercial <br /> Number of living units: Numberof bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: , No. Compartments <br /> ❑ Type/Mfg Capacity__.�- <br /> I SEPTIC TANK F - Method of Disposal <br /> PKG. TREATMENT PLT. ❑ property Line <br /> I Distance to nearest: Well Foundation <br /> sTotal length/size <br /> LEACHING LINE ❑ No. & length o1 lines <br /> FILTER BED El Distance to nearest: <br /> Well <br /> Foundation Property Line <br /> I fF <br /> Number <br /> SEEPAGEPITS l.i Depth I Size — -. .-�—� <br /> i' - Foundation Property Lin <br /> II SUMPS I AL1 Distan <br /> {{ce to nearest: Well e <br /> DISPOSAL PONDS ❑ f <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 Yaws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> j 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 signature <br /> shall not <br /> [ employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's Asns'sub'ect to workmantind or tlsQompensa- <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ p 1 <br /> tion laws of California." <br /> The applican st tail IV required inspections. Complete drawing on reverse side.�����r <br /> - <br /> - Title: - <br /> Date: <br /> KSigned X <br /> FOR DEPARTMENT USE ONLY <br /> -- .Date. v Area <br /> ApplicationAccepted by <br /> Final Inspection by Date <br /> Pit or Grout Inspection by Date�— <br /> Additional Comments: y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 37104 ❑ Tracy 835 6385 <br /> Applicant Return all copies to: vironmental,}iealth PermFL/SeNI es 1601 E. Hazeltan Ave., P.O. Box 2009, Stk., CA 95201 <br /> 353 � �� �7 <br /> ,G , , - <br /> r C RECEIVED BY DATE PERMIT NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO � � <br /> + ER 13-24(REV.I/y sl <br /> 3 J5- <br /> EH 14-26 } <br />