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4 � s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Y <br /> 1601 E. HAZEL T ON AVE:, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 71. (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 �, i E�h City Lot Size PM <br /> Owner's Name. �`9 . v ` /�Y Address Phone <br /> ContractAddress - ej:�fi +' License PhoneF U ; <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT EJ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER FV <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ' Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _-4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> 4 Repair Work Done ❑ Type of Pump H.P. r State Work Done <br /> Well Destruction El Well Diameter <br /> Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ViNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> f Character of soil to aept of 3-feet: r Water table depth <br /> SEPTIC TANK Type/Mfg _ Capacity-6-0-0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well ° Foundation Property Line' _ <br /> s j <br /> LEACHING LINE El No. lenth No. & Length of lines g /size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r f <br /> SEEPAGE PITS ❑ Depth _ Size Number I r <br /> SUMPS 1-1Distance to nearest: Well W ` Foundation Property Line <br /> DISPOSAL PONDS ❑ l <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 /> fff rules and regulations of the San Joaquin Local Health District. ' <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, 1 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." <br /> • r~ <br /> r The applicant m t call for all required inspections. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: l6 <br /> FOR DEPARTMENT USE ONLY <br /> 1*01 <br /> Application Accepted by Date e. Area <br /> Pit or Grout Inspection Date 4 Final Inspection by Date ? <br /> Additional Comments: � I� J— / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDC RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +'EH 13-24tREY.1/857 <br /> EH 14-Z ✓ <br />