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APPLICATION FOR PERMIT , vQ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ­� -1601 E. HAZEL i ON AVE.-, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) � i7J ro(f)rt, & 7 3 <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 4 <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 ' City PM <br /> cave <br /> Owner's Name ,Address Phone <br /> Contractor Address �'�l 9rh License No. Phone <br /> TYPE OF WELT./PUMP: NEW WELL �. WELL REPLACEMENT.I] DESTRUCTION El ; <br /> PUMP INSTALLATIONSYSTEM REPAIR ❑' 0THFr ❑ a <br /> DISTANCE TO NEAREST: SEPTIC TANK ' 2450 SEWER LINES DISPOSAL,FLD. C! PROP. LINE 2=5 <br /> FOUNDATION zS AGRICULTURE WELL ---= OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1. r <br /> j <br /> Domestic/Private XGravel Pack ❑ Tracy Type of Casing ¢= Specifications <br /> FI Public Cl OOtper Ll Delta Depth of Grout Seal -� Type of Grout y• j <br /> I I Irrigation O_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump _-__ _ H.P. +�'L -State Work Done ' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i,l REPAIR/ADDITION l I DESTRUCTION•I 1 'lNo septic system permitted if PLAAC sewer is <br /> `'available within 260 feet:) +� <br /> Installation will serve: Residence_ Commercial--:.- Other <br /> r d <br /> Number of living units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ k �„ Method,of Disposal <br /> Distance to nearest: Well Foundation ° Property Line - 1 <br /> k <br /> LEACHING LINE - ❑ No. & Length of lines Total.length/size ; { <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation Property-Line L <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property.Line <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 laws, and <br /> rules and regulations of the San Joaquin Local Health District. c <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 person in such manner as to become subject to workman's compensation taws 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.persdns-subject to workman's compensa- <br /> tion laws of California." x,' r r <br /> applicant II re u' coons. Complete drawing r <br /> se e. <br /> Thea <br /> PP q p 9on <br /> Signed X _ f/ Title: -_ Date:1 <br /> FOR DEPARTMENT USE ONLY,d --r <br /> Application Accepted by ` ` Date a Area y ` <br /> Pit or Grout Inspection by Date 'V Final Inspection by "p Data) 1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tra4 835-6385 : t . z.r <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> -nG 1�� /a �crr . �ro� c/ave l ihS t'�Gir (,, 231 'SSrY� <br /> FEE AMOUNT DUE AMOUNT REMITTED CKRECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH13-241rrEV.tins( -7 <br /> EH 14.28 <br />