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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 <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 /> Joh Address �. City Lot Size �D PM <br /> V + <br /> .lu � '�none a� <br /> "Owner's Name Address n <br /> Contractor • -�� '4a�T�2 Address ��41 'License No. ����/ Phoney Z�40 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> r PUMP INSTALLATION ❑ ? SYSTEM REPAO4 OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _'_`� DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> F INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E] Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing t Specifications <br /> �.r <br /> ❑ Public ❑ Other. ❑ Delta Depth of Grout Seal i YPe i <br /> El Irrigation Approx. Depth:."!.O Eastern Surface Seal Installed by ; <br /> Repair Work Done ❑ Type of Pump `s H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 i <br /> Depth Filler Material tBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION 11INo septic system permitted if public sewer is <br /> ILI <br /> ` available within 200 feet.} 09 <br /> i Installation will serve: Residence K Commercial_ Other , <br /> Tom'"Nu"rnbeT of living"units:•^/, Number of bedrooms t <br /> Character of soil to a depth of 3 feet: � � Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ( <br /> �-n-M--PKG:TREATMENT PtT-❑- ,,r. t Method of Disposal } , <br /> ,; Distance to nearest: Well Y Foundation Property tine) l <br /> LEACHING-LINE'_ ' ❑ No. & Length of lines Total length/size <br /> FILTER BED Jll Distance to nearest: Well/_0 OFoundation Property Line 20 <br /> SEEPAGE PITS ❑ " Depth Size i Number i <br /> y i E <br /> ,SUMPS ❑ 19 Distance to nearest: Weil l Foundation Property Lina-••--- -- <br /> f DISPOSAL PONDS ❑ '" r.- q� <br /> <.I hereby certify that I have prepared this application and that the work will be done in accordance with San�Joaquin county ordinances!s ate laws, and 1 <br /> { rules and regulations of the San Joaquin Local Health District. i ( I , <br /> t Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued,Iihall not <br /> :employ any person in such manner as to become subject to workman's compensation laws of California:"Contractods Hiring or�sub-contract'ing signature <br /> certifies:the following:"'fcertify"that'in the perforrtmahce of the work for which this permit is issued, I shall employ persons subject to workman''s compensa <br /> #tion law's of California." <br /> P" 1 <br /> The applicant must c r 'i r wire- ' 's�iectj . omplete drawing on reverse side. ,`*-� *✓'��---r" J <br /> ' Title: w " Date: <br /> ;Signed• — - }} <br /> i' <br /> " t . . FOR-DEPRl.�- TMENT-USE'ONLIf <br /> �ry <br /> . ' � 1ii r Date � Area u <br /> Appliciation Accepted by / <br /> Hato <br /> _Pit or Gfout Inspection by Date Final Inspection by <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 AManteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant=Return-all-copies•to:-Environrnan -Neo h Perrnit1Servlces 1601 E. Hazelton Ave., P.O. Box , Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY S �* DATE r ,,PERMIT'NO. <br /> INFO GASH "` <br /> �- <br /> + EH 13-241REV.m/e51 <br /> EH 14 V <br />