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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i 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 instail 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 .5 <br /> City Lot Size PM <br /> Owner's Name - Address Phorie <br /> Contractor .F• <br /> Address License No $ Phone <br /> TYPE OF WELL/PUMP. -7-NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _SYSTEM REPAIR C1 OTHER 1-1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> INTENDED USE TYPE OF WELL---PROBLEMAREA--CONSTRUCTION-SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation a <br /> Dia. of Well Casing <br /> 1-1 Domestic/ ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r i <br /> El Public 4 �❑ Other El Delta Depth of Grout Seal "rt <br /> Type of Grout <br /> ❑ Irrigation * I Approx. Depth ❑ Eastern <br /> g `�' y., P Surface Seal Installed by e <br /> Repair Work Done ,_❑W--Type of Pump H.P. State Work Done <br /> I Well Destruction ❑,.a Well Diameter. --- - - .Sealing Material{top 50'1-.- t t <br /> Depth vU <br /> t Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION F1 -Aller <br /> k DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will serve: Residence✓ Commercial_k Other a N <br /> ,,,_Number of-living units:,--3 Number of bedroloms <br /> Character of soil to a depth of 3 feet: Lamm <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg i t Capacity L No. Compartments <br /> PKG. TREATMENT PLT, Q l <br /> - , Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> '� _ 1 '� is t f,ia♦,�• r <br /> LEACHING LINE l�No. & Length of lines — d Total length/size ' ?b <br /> FILTER BED i ❑ Distance to nearest: Well ATO 4; Foundation A2 Property Line <br /> SEEPAGE PITS ; p Depth SizeJ -Number' <br /> S <br /> SUMPS ❑ Distance to nearest` Well 112 Foundation Property Line <br /> DISPOSAL PONDS ❑ j ! <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 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 fol-Which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." < <br /> Tlie app Ilcant m it for al re d inspections.YComplete drawing on reverse Sid <br /> Signed <br /> Title: r .f <br /> . _ Date:Y � <br /> FOR DEPARTMENT USE ONLY E y ` <br /> b <br /> Application Accepted by _ <br /> Date Area <br /> `Pit-or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments <br /> ❑ Stk 466-6781 ❑ Lodi ,369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental AHealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE` PERMIT'N0. <br /> INFO CASH <br /> + EH 324(FIEV.tie 5) <br /> EH 14.25 v ' ` ] .7 <br /> I <br /> —!S-42_0. �' <br />