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APPLICATION FOR PERMIT :mow <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heieby 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. k <br /> �j �j 4A,47L <br /> �LJob Address �+ 7 7 f "i Cify Lot Size PM <br /> i <br /> Owner's Name Address <br /> --- Phone <br /> Contractor /" t T 14" Address License No. A Phone <br /> TYPE OF-WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 11OTHER Cl <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. . ..AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> _ INTENDED USE TYPE OF WELL :PROBLEM AREA" CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom El:Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack l �❑ TracyType of Casing Specifications + <br /> .0 Public { ❑ Other F],Delta Depth of Grout Seal Type of Grout <br /> +Irrigation 1 --Approx. Depth"1 ] Eastern Surface Seal'lnstalled by- <br /> Repair <br /> y Repair Work Done .❑ Type of Pump 1;r H.P. State Work Done - YJ <br /> _ Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> �--Depth f--v. Filler Material IBelow 50') V <br /> TYPE OF SEPTIC WORK: .NEW-INSTALLATION Cl REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is ill <br /> 4 "* available within 200 feet.) <br /> Installation will seine: Residence Commercial Other , <br /> k;M Number of living units: Numbenof begkooms <br /> Character of soil to a depth of 3 feet: • / Water table depth <br /> SEPTIC TANK: " , ❑ TypelMfgl Capacity . No. Compartments <br /> .+� <br /> PKG. TREATMENT PLT. ❑ � ,.?Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE VCNo. & Length of lines " !10 Tata length/size �% 1 <br /> FILTER BED JDD' tan to nearest: Well Foundation� Property Line <br /> t ILe <br /> r � <br /> SEEPAGE PITS I 1 Depth` + Size - ' Number <br /> SUMPS _ ❑ Distance to nearest: , Well Foundation Property Line <br /> DISPOSAL PONDS l CJ <br /> c-1 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 /> P-certifies the following, "I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." k. <br /> The appliAN musA call for all roqwrad ins tions. mplelefdrawing~on reverse side. +� `7t/e <br /> 5 <br /> Signed rp f Title: / ` 6 Date: <br /> F' FOR DEPARTMENT USE ONLY <br /> Application Accepted by �'' .,Date £/ ��` +Area F <br /> Pit or Grout Inspection by.. y '- Date Final 1hspection.by-' {` Date <br /> Additional Comments: ° <br /> ❑ Stk 466;6781 ❑lodi 369-3621µr z.. ❑ Manteca�A823-7104 y❑_Tracy;, 63 <br /> 835- 85 ___ <br /> Applicant- Return all copies.to: Environmental HealiF'Permit/Services 1601,E.-Hazelton Ave,-P.D.'Box 2009,'Stk -CA 95201 <br /> [FEE' AMOUNT DUE,4- AMOUNT REMITTED CK. RECEIVED BY DATE PERMITNO.FO - H <br /> + EH 1324 tREv,t r H 5) ��/�� ....-O�'s;�C� 1"1 L4il , J^ .! <br /> EH 14-28 <br />