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t <br /> APPLICATION FOR.PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone.(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED l <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 /> Lot Size 2 ���—-. PM <br /> Job Address ' <br /> 1- Jam, � <br /> Owner's Nam - C�-IG� - Address / �► I � - - Phone <br /> e. <br /> Addres 1' K- cense No. Pho <br /> Contractk-j / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP.INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> F t <br /> s DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. L <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> f; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom L1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r + Specifications <br /> Q Domestic/Private ❑ Gravel Pack ❑.Tracy Type of Casing P <br /> FI Public l l Other F] Delta Depth of Grout Seal Type of Grout - <br /> I I Irrigation __Approx. Depth I I Eastern Surface Seal installed by <br /> i H.P. State Work Done <br /> Repair Work Done ❑ Type of Pump q <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50') �1 <br /> Depth J Filler Material (Below 50') <br /> TYPE OF SEPTIC WOflK: NEW INSTALLATION Ll REPAIR/ADDITION DESTRUCTION I l INo septic system permitted if public sewer is <br /> i C available within 200 feet.) <br /> Installation will serve: Residence Commercial Othe �7 <br /> Number of living units Number of bedrooms / <br /> Character of soil to a depth of 3 feet: Water table depth <br /> Anc <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT, ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> I <br /> LEACHING LINE No. Length of line Total length/size <br /> r _., <br /> FILTER BED LJ Distance Property Line Distance to nearest: Well�='f F <br /> SEEPAGE PITS Depth. Size Number l <br /> I <br /> SUMPS L1 Distance to nearest: Well /OD Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> 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 /> I ertify that in the performance of the work for which,this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I c <br /> employ any person in such manner a''sto 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, I shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant must tali for all reg fired in ctions. Co ete drawing Q reverse side. <br /> Signed 3( Title: Date: ' <br /> FOR DEPARTMENT USE ONLY <br /> C� C <br /> lication Accepted by Date �� L Area <br /> Pi r Grout Inspection by ���#�� Date (nal Inspection by Date <br /> 4 Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 95201 <br /> t= <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> 4 INFO y <br /> ! +.EH 13.24(REV.I/A 5) 4--D �O a <br /> EH 14-28 <br /> E <br />