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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT PAYMENT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 RECEIVED <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED APR 2 5 1gRn <br /> (Complete in Triplicate) SAN JOA UiN COUNTY qhe �!Li H �� � <br /> Application is hereby made to the'San Joaquin Local Health District for a permit to construct and/or install t i ion is <br /> made in corr2Pliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the u r � gain <br /> Local Health District.-36 / <br /> rfv i <br /> Job Address) /�' ` City Lot Size Pial <br /> tn,es Name 1,r^'�/2 -"� Address ! MPhoneZ09- ,V16 f <br /> tor Address �� i , C�L�ense No.e- `I<W( Phon <br /> TYPE OF WELL/P MP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ W' <br /> PUMP INSTALLATiO ❑ SYSTEM REPAIR ❑ ow 0-6011- �Qi'Cb S <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES <br /> '" DISPOSAL FLD.� PROP. LINE <br /> FOUNDATION � �U AGRICULTURE WELL OTHER WELI_2 5 ' PiTSLSUMPS �►� Ly <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J <br /> 1p(l-dustrial El open Bottom ❑ Manteca Dia. of Well Excavation n � Dia. of Well Casing A <br /> F-1 Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing NJI Specifications <br /> i'1 Public Other f7v I C Q, <br /> 013bo C1 Delta Depth of Grout Seal P__ W_ _ Z. Type of Grout <br /> 1Zin1(r• --- <br /> 1.1 Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done U Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Seating Material itop 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIAODITiON I 1 DESTRUCTION I I lNo septic system permitted if public sewer is 1 <br /> available within 200 feet.) <br /> Installation wilt serve: Residence_ Commercial_ ,Other <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Water table depth _ <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.El Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE D No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS 11 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I <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 Di';trict. <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 shall employ persons subject to workman's compensa- <br /> tion laws of Califon 'a." <br /> I <br /> The applicant ust all for requ' spectio s. omplete drawing on reverse side. <br /> ql.�)0 <br /> Signed X Title: _„_ Date: Z <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 6 _ Data SQ Area T 3Z <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 Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED K RECEIVED BY DATE PERMIT'NO. <br /> • EH r3d�(REV.iiNS� /'7Z 1 <br />