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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 /> Job,Addre'"ss" �. // City rz xo x lc)aa Size RM <br /> i <br /> Phorie ._-w. <br /> Owner shame <br /> Contractor License No.1467 m Phone 1 <br /> TYPE OF WELLIPUMP: __-1VE.W._W-.ELL_ a IiVEL.!I,REP,L-AC iMENT-0--—DESTRUCTION-C]- r--- . <br /> PUMP INS TALLATJ.ON --- -�---- 1 SYSTEM..RFPAIR-L _OTHER.O• <br /> DISTANCE TO NEAREST:'SEPTIC ANK .._ SEWER LINES �--.—,s{ ;IDISP;O45AL F:LD.�� PROP. LINE �p <br /> . - FOUNDATION...—":�AGRIC_ULT_URE,WELL_ r7THER'WELL c=:7=ITS/SUMPS <br /> INTENDED USE t TYPE 3F WELL PROBLEM AREA CONSTRUCTION SPECII IBATIONS d <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casino <br /> ❑ Domestic/Private Gravel JPack ❑ Tracy Type of Casingrn � Specifications �'� <br /> C I Public 1-1 OtVr n Delta Depth of Grout"Seal Tyne of Gfout_..4� <br /> irrigation Approx. Depth l 1 Eastern Surface Seal Installed by -_ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ f <br /> Well Destruction ❑ Well Dia etef Sealing Materi�al_ftop 50'1 1 <br /> Depth Filler Material�IBelnw�50'.) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION-I I (No septic system permitted if public sewer is <br /> available within 200 feet.) a 00 <br /> 1 � <br /> V nstallation will serve: Residence._ Com Qial=Rm <br /> Number of living units: Number of bCharacter of soil to a depth of 3 feet: '� Water table depth }. <br /> SEPTIC TANK LJType,Mfg Dnrt9r�1 fClSiif � ( IRED <br /> +h�}i IhDt No. Compartments <br /> xPKG. TREATMENT PLT..p �� _ } Method of Disposal f + <br /> F ' Distance to nearest: f E=tl �oun 4itlon ' Property Line <br /> ,rla <br /> LEACHING LINE s, ❑ No. & Length of lines r, ��\ Total length/size f I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS r l I Depth Size Number f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ = i <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. <br /> Homeowner 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 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." j <br /> 1 <br /> The applicant s r requir ions. Complete drawing on W vv`0se side. i <br /> Signed X itle: T` lr 3J Date: <br /> { <br /> OR DEPARTMENT USE 4LY <br /> �r .. <br /> —Application Accepted by Date ^� Area Cs) <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> -Additional Comments: j <br /> Stk 466-6781_..,.--.Q-Lodi-369.3621 D Manteca 3--7'184—❑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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO 41 CASH <br /> a-EH 13-24iREV,t/Hbf - '""� / �( / <br /> EH 14-Itt • Z)v <br />