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'r <br /> ` J f APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> { 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> ' (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for 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 wail/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f <br /> ` J CitJ Size 141.1 {'' V PM <br /> Job Address <br /> E Address Phone <br /> Owner's Name <br /> Contractor <br /> Address � - License No.?�Phone - 4 <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION O <br /> TYPE OF WELL/PUMP: <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> OTHER E3 <br /> t D15POSAL_FLD,_ PROPI--- <br /> FI <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES - <br /> SEPTICFOUNDTION AGRICULTURE WELL OTHER WELL PITS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specific <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Public ❑ Other C1 Delta Depth of Grout Seal <br /> r _ A rox. Depth l I Eastern Surface Seal Installed by <br /> - <br /> I'I krgation Pp p. { <br /> i Repair Work Done ❑ Type of-Pump H.P. State Work Done _ <br /> Well Destruction: 11Well Diameter' Sealing Material'itop 501 a <br /> Depth Filler-Material IBelo r`) <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIRlADDLTION l _(IV, CTlON I i availablel6 system wi within 200 feetit�ed if public sewer is <br /> y <br /> Installation will serve: Residence— Commercial- Other / <br /> Number of living units: NumJbef of beifroerns��_ <br /> Character of soil to a depth of 3 feet: 0 <br /> I Water table depth <br /> + ArJ� Ca acit dCa No. Compartments <br /> SEPTICfTANK ❑ Type/Mfg � p y-1C�— <br /> i J Method of Disp sal <br /> PKG.tTREATMENT PLT. ❑ f l f�; <br /> Distance to riZ'earest: Well�9 Foundation ,Property.line <br /> I 3 <br /> LEACHING LINE CoL No. & Length of likes / — r Total length./sizei <br /> F FILTER BED ❑ Distance to nearest Well 1,0-0. Foundation T/E$� Property Line <br /> t r <br /> +a € u <br /> SEEPAGE PITS � 'j Depth ; � Size? mber <br /> �,,,•N<� � <br /> SUMPS' Ll Distance to nearest: } Well�(�— Fo ndation -.— Property Line Lm j <br /> DISPOSAL PONDS ❑ <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 Healih Di1trict. <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 shat!not <br /> employ <br /> 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." A <br /> ' The applicant s call f all requ'ed inspections. Complete drawing on reverse side. i , - <br /> "t ; l Date: <br /> Signed X Title: -9 ` <br /> ' FOR EPARTMENT USE ONLYArea <br /> _ <br /> kApplication Accepted by Data <br /> Date Final Inspection by Date <br /> Pit.or Grout Inspection by - <br /> Additional Comments: .. <br /> ❑ Stk 466-6781 ❑*Lodi -3621 M race 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2005, Stk., CA 95201 <br /> CKOFEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> d 3 <br /> i.EH 13 -31-��24IREY.tins/ � � <br /> EH 14-28 <br />