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II <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ,I (Complete in Triplicate) ty <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 /> u549 in County Ordinance No. for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaq *.., <br /> Local Health District, l h �] / �( <br /> ( iWI / City � ��/d Lot Size PM <br /> Job Address /' <br /> t'C JGI M e�/Address �7(f� �7'. — Phone car✓ �"v� <br /> Owner's Name ' <br /> License No. Phone <br /> Contractor Address <br /> TYPE OF WELLIPUM NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTAL © SYSTEM REPAIR C] 0TH <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> reg <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> l omesticlPrivate El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1 Public R Other Ll Delta Depth of Grout Seal Type of Grout <br /> L� <br /> i1 Irrigation Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State.Work Done <br /> ` Well Destruction ❑ Well Diameter Sealing Material )top 50') <br /> Depth .Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION t I DESTRUCTION (N <br /> i ailabpetic <br /> wthin te200 feetitled if public sewer is <br />{. <br /> I Installation will serve: Re idence x_ Commercial_ Other <br /> Number of living units: Number of bedroom <br /> Character of soil to a depth of 3 feei <br /> SEPTIC TANK 171TypelMfg >-Water table depth <br /> f Capacity. No. Compartments <br /> , <br /> f PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Il Distance to nearest:�, Well Foundation Property Line <br /> a { Total len thlsize <br /> 4 LEACHING LINE ❑ it No. & Length of lines e g <br /> F FILTER BED ❑ 1 Distance to nearest Well " Foundation Property Line <br /> \JJJ ih <br /> SEEPAGE PITS l 1 :i Depth Size Number <br /> SUMPS ❑ 4-Distance to nearest:= Well- -•Foundatioh Property Line <br /> 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 which this permit is issued, I shall not <br /> I 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 /> a - x <br /> The applicant m st call for alt required inspections. Complete drawing on reverse side. q <br /> Signed X s1-� <br /> Title: Date: l <br /> r : <br /> " FOR DEPARTMENT USE ONLY <br /> SFJ r- f <br /> I Application Accepted by Date a <br /> Pit or Grout Inspection by Date w Finei inspection by .__ ✓ '� Dat <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manted 823-7104 ❑ Tr8 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 CASH RECEIVED BY DATE PERMIT iv0. <br /> INFO `�/ I <br /> r.EH 13-21(REV. <br /> EH 1428 <br />