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{° TION FOR PERMIT <br /> APPLICATION <br /> 1 SAN JOAQUIN`LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON yAVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r�Y1 <br /> PERMIT EXPIRES 1-YEAR'FROM DATE ISSUED <br /> f {Complete in`Triplicatp <br /> t /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 welllpump and the Ryles and Regulations of the San Joaquin <br />;. Local Health District. <br /> Ci of'Size PM <br /> Job Address r <br /> T 631 <br /> k Address Phon <br /> Owner's Name E&—Z <br /> Contractor rens <br /> License No. "/ P Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT LJ <br /> LJ <br /> i PUMP INS FALLATION SYSTEM REPAIR ❑' OTHER ❑ <br /> DISTANCE TO NEAREST`SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION--:.�•% _t AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> r r Type of Casing Specifications <br /> �omesticlPrivate fl Gravel Pac Ll Tracy 9 <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Se31 Type of Grout <br /> El Irrigation --Approx. Depth Ea term rface�"Seaitl stalled;by <br /> Rept Work-Done !=tate <br /> ' WeA Destruction ❑ Well Diameter Sealing Material (top 50'1 } (A <br /> _.--) 6 <br /> 1 r Depth Filler Material (Below 50'} <br /> r TYPE OF-SEPTIC"WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 bed;'oomsl- <br /> Cha-racter of soil to a depth of 3 feet: ' e`ti§ Water table depth <br /> SEPTIC TANK E3Type/Mfg - Capacity No. Compartments <br /> ` Method of Dispose{ <br /> PKG.,TREATMENT PLT. 11 *�`<s t <br /> f f Distance to nearest: Well Foundation Property Line r <br /> rTotal length/size <br /> LEACHING LINE-- ONo. & Length of tines <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> � r <br /> SEEPAGE PITS El Depth <br /> Size: y t Number i <br /> SUMPSt ❑ r Distance to nearest: WeH)­�\*'*, Foundation- iProperty Line <br /> -J : <br /> j 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 Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for whichihis 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 th9 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 df California." <br /> k The applicant must call for II required inspections. somplete drawing on reverse side. I <br /> f Date: <br /> Signed Title: i <br /> r FOR DEPART ENT USE ONLY <br /> zl , � Date 2 ) - Area <br /> Application Accepted by <br /> I Pit or Grout Inspection by Date Final Inspection by Date - <br /> . - <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE' PERMIT N0. <br /> INFO i. CASH <br /> + EH 13-241AEV.x <br /> EH 1426 <br />