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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (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 tot sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> „� <br /> Job Address P City Lot Size IdAfk SIS PM <br /> 4 /� 4 <br /> Owner's Name � 041ress �- Phone <br /> Contractor � `!` ""� Address__. icerise No. .ill Phone Q _&a' <br /> i TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> "PUMP INSTALLATION ❑ SYSTEM REPAIR ❑- OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION __ AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> 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 E1 Gravel Pack Q Tracy Type of Casing Specifications <br /> M.Public (=1 Other F1 Delta Depth of Grout Seal Type of Grout _ <br /> 4 f I Irrigation --Approx. Depth LI Eastern Surface Seal Installed by _ <br />{ Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameters Seating Material )top 50') (� <br /> - �. <br /> . . � Depth ti Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAiR/-ADDITION 1 I DESTRUCTION ( I (No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> installation will serve: Residence_ Commercial_-at Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of,3 feet: f (. Water table depth <br /> ,; ; <br /> SEPTIC TANK t Type/-Mfg.- *=4 r Capacity 1. No. Compartments <br /> R PKG"TREATMENT PLT. ❑ t -_ Method of Disposal <br /> `istanceto-nearest:—Well" Tourfdatibh- -- +Prnperty Line <br /> LEACHING LINE 0 No. & Length of lines .k Total length/size <br /> FILTER BED ❑ Distance,to",ares • Well—I Foundation Property Line <br /> SEEPAGE PITS I I Depth '61OXSize e (���^ Number" <br /> SUMPS Distance to nearest: Well t Foundation � _�'Property Line <br /> DISPOSAL PONDS ❑ l` -y f " `}'"' ± <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 /> I rules and regulations of the San Joaquin Local Health District. ; w <br /> Home owner or licensed agent's signature certifies the following, I certify i&i in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation'latnrs of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of fhe work for which this permit is issued;i shall employ persons subject to workman's compensa- <br /> tion laws.of_California.'— <br /> The applican m all for al d inspections. Complete drawing on reverse side., <br /> Signed.X Title Date: <br /> loFOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date Areaj_, <br /> f Pit or Grout Inspection by Date Final Inspection by Date 1 O q <br /> 9 <br /> 4 Additional Comments: I <br /> ❑ Stk 466-6781 0 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 2009, Stk., CA 95201 <br /> FEE i <br /> I INFO AMOUNT DUEAMOUNT REMITTED CK RECEIVED BY DATE PERMIT'No. <br /> a.EH 13-28IREV.tiH5Y <br /> 7000 <br /> EH Ut-28 7Q 0 �� � j—' � �A L <br /> E UU i..•t�� <br />