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APPLIeATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> kTelephone (209) 466-6781 <br /> ' 43 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 4 ' <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 Address a � Q / PM <br /> City Lot Size / <br /> J. <br /> Owner's Name 1 1�rel n C Address Phone :z'L2!1 .� .f' s" <br /> .,,.z � �• .. <br /> Contractor Address License No. s .�i`i"t_Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PU[tA P'tN STA LLATIO N•..O-.--••_-��-----•--51�5 TE M-RC PAI R-❑--��--�.-.�.----OTHER-C�-_•,,.�...,•--•. <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES. DISPOSAL FLD. PROP.'LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> i INTENDED USE TYP9 OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Opehi Pack ❑ Trac Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> El Domestic/Private C18raJel Type <br /> 11 Y Yp of Casing Specifics[ions <br /> Public Cl <br /> (`l &Wh r Cl Delta Depth of Grout Seal _ Type of Grout <br /> I ! irfigadon ,.Abprox. Depth l I Eastern' Sd'rface-Seal-lnstalled by— } i <br /> Repair Work Done 13 Type of Pump H,P. f — - State Work Done <br /> Well Destruction ❑ Well Diameter Sealing.IVlate'riaE (top 50'I <br /> Del1 E � ,v <br /> Depth Filler hAaterial'fBelow 50') <br /> `,TYPE OF SEPTIC WORK: NEW INSTALLATION K ?REPAIR/Xt)oiTIONi.I 1 DESTRUCTION I'TI(No septic system permitted if public sewer is [� <br /> available within 200 feet.l 1 <br /> Installation will serve: Residence Commercial_ Other �] <br /> Number of living unit' iNumh of bedroom <br /> Character of soil to a depth�of 3 feet- / Water table dem <br /> SEPTIC TANK ❑I-Type/Mi }� <br /> PKG. TREATMENT PLT. CI .SIE g �� �Y o„ Compartments.' <br /> Metinod of Disposal <br /> Distance to nearw W-19 U', Foundation Property Line <br /> LEACHING LINE Cl No.4 Len th of lines} <br /> I 9 t Total length/size i <br /> FILTER BED ;.[ Distance to nearest: 1 -.-Well-- Foundation- --------.---property.Line <br /> SEEPAGE PITS l I Dep�h Size Number '� I <br /> SUMp5 - Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that I have prepare)d 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 District. I a <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 n in such mar{ner;as to become subject to workman's compensation laws of California."Contractor's tiring of sub-contracting signature <br /> certifi a 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 I ws of California.' <br /> i� j <br /> The app ust ca or all inquire ins ctions. Complete dr wing on r erse side. <br /> i <br />' Signed X I Title: _ Date: jG <br /> FOR.DEPARTMENT USE ONLY­----�--�.-�--_.��....,._... <br /> Application Accepted by ��- <br /> Date AreaTb <br /> f' a <br /> Pit or Grout Inspection by Date Final Inspection by Date e <br /> Additional Comments: <br /> ❑ Stk,•466-4781 0 Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> FEE�f? INFO �AMOUNT DUE �AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> .,EH .?4,IrtEV:tiK5i / V l • 16d6w)� / <br /> EH 1 _28 ! H <br />