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APPLICATION FOR PERMIT r� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781, „. <br /> PERMIT EXPIRESA.YEAR FROM DATE ISSUED <br /> .-.4,(Complete in Teiplicate) ` <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 for sewage or No_ 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. * s <br /> Job Address �_ "` " " CityLot Size 10 PM <br /> r � /7 <br /> ' AddQ[.�-,Z Phone <br /> Owner's Name Address � - I <br /> ��/'t <br /> Contractor ddress License No/-2 4v_ Phone . <br /> TYPE OF WELL/PUMP.— NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR E1 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OWELL PITS/SUMPS <br /> CONSTRUCT SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C , ` <br /> -, ,, <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. o ell Excavation Dia. of Well Casings <br /> ❑ Domestic/Private ❑ Gravel Pack. ❑ Tracy pe of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation 1 —Approx. Depth 01as <br /> ern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ W 41`'Dia Sealing Material (top 50') <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑. REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet I <br /> Installation will serve: Residence_ Commercial Other ~� ^`� <br /> DAR— <br /> Number of living units: Number of bedrooms {VSO <br /> Character of soil to a depth of 3 feet: Water tabl depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Totai length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> l i• <br /> SEEPAGE PITS ❑ Depth ~µ^ Size ;Number <br /> SUMPS 1) Distance to+nearest: Well Foundation ' r Property Line <br /> DISPOSAL PONDS ❑ `' { <br /> I hereby certify that I have prepared this application and that the work will kbe 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 /> 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 steal!employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. C mp to drawing on r erse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> r ' t TO <br /> Application Accepted by' Date Area <br /> Pit or Grout Inspection ' ' ,,� <br /> Date Final Inspection by �"�"' Date <br /> 1. <br /> Additional Comments. <br /> ❑ Stk 466-6781 Lodi�3629-3�621 - ❑ Manteca 823 71 ❑ T�' 83� <br /> 485 J <br /> Applicant- Return all copies to: Environme tal He h Per Services 1601 E. Hazelton Ave., P.O. Box tk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY TE PERMIT''NO. <br /> INFO <br /> +EH13-24MEV.1/a57 <br /> EH 1428 <br />