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APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 4209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 Addres ` •� » r r / <br /> �:. <br /> Y Lot Size JV,,ePly <br /> Owner's Name Address C� Q <br /> Phone `; <br /> Contractor <br /> Address n License No. Pho <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK i SEWER LINES <br /> f DISPOSAL FLD. OP. LINE <br /> FOUNDATION AGRICULTURE WELL OT LpIIS/SUMPS f_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONST N SPECIFICATIONS , <br /> ❑ Industrial El Open Bottom. ❑ Manteca la. of Well Excavation t Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack 1❑ Type of Casing Y <br /> ' M Public j Specifications !i <br /> f7 Other , l Delta Depth of Grout Seal } <br /> I ! Irri anonType of!Grout <br /> 9 t rox. Depth ' I I Eastern Surface Seal Installed by' j <br /> f Repair Work Done ype ,,Pump s ' H.p r - <br /> State Work Done_ <br /> Well Destruc' ❑ Well Diameter i _Sealing Materia! ltop 501} s <br /> Depth Filler Material (Below 50'1 l <br /> TYPE OF SEPTIC WORK: .NEW INSTALLATION f 1 REPAIRYADDITION i I DESTRUCTION' I {No septic system permitted if public sewer is <br /> I t <br /> available-.within 200 feet.) <br /> Installation will serve: Residence_ Commercials' Other b..+ a <br /> Number of living units: Numher�of bedrooms <br /> Character of soil to a d-pp of 3 feet: <br /> I water table'depth: -fir <br /> SEPTIC TANK Type/Mfg i ",y` m° "tea... {- �.,._,. <br /> Capacity T No. Compartments t <br /> PKG. TREATMENT PI <br /> ., LT. ❑ � <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length Of lines t <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest : Well Foundation F <br /> A. } Property Line <br /> SEEPN <br /> AGE PITS I ] Depth I Size { <br /> Number � <br /> SUMPS ❑ Distance to nearest: Well Foundationr � <br /> DISPOSAL PONDS ❑ ;#! Property Line <br /> I hereby certify that I have prepared this application and that the work will be done in <br /> _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 agents signature certifies the following; "I certify <br /> that in the performan a 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, I shall_employ.persons.subject to workman's compensa- <br /> tion laws of California." }i}i� <br /> The applicant mus a for all r ire spections. Complete drawing on reverse side. <br /> Signed'X rl r <br /> r Title: <br /> . Date <br /> FOR DEPARTMENT USE.ONLY <br /> a <br /> Application Accepted by <br /> Date — ea <br /> Pit or Grout Inspectio DateP I <br /> Final Inspection.by_ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 El Lodi 369- <br /> 36211 ❑ Manteca 823-7104 fl Tracy 635-6385 <br /> Applicant - Return all copies to: EnvironmantahHeglth Permit/Services 1601,E.-Hazelton.AVe., .P..O, Box 2009, Stk.,-CA 95201��. <br /> J [[ n•R <br /> FEEt <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY, PATE <br /> PERMIT'NO. <br /> * EH14-29(REV.Fin5) ,�� 19 Le 2q <br /> EH 14-2a <br />