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4 <br /> i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />{� (Complete in Tripficate) <br /> k 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. `�� <br />� /',r,,�.,_f--Z�� J�•i:i q <br /> Jab Addressy. add -Ck o a .� O <br /> t � <br /> `q .City Lot Sized f� PM <br /> Owner's Name Address �a=.�✓f <br /> A Phone <br /> Contractor's Name F J <br /> License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ -�� �, Phone I <br /> WELL REPLACEMENT ❑- -..a-_.DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE f <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ 0 en Bottom <br /> p ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ID Gravel Pack Dia. of Well Casing <br /> C1 Public ❑ Tracy Type of Casing <br /> ❑ Other ❑ DeltaSpecifications <br /> EJ Irrigation Depth of Grout Sea! Type of Grout <br /> Repair Work Done <br /> ---Approx. Depth L3 Eastern Surface Seal Installed by �� <br /> ❑ Type of Pump H P <br /> Well DestructionState Work Done C)Welt Diameter -Z4= <br /> Sealing Material ftop 50'1 k <br /> Depth. _ Filler Material (Below 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ [No septic system permitted if public sewer is <br /> l <br /> Installation will serve. Residence— Commercial— Other available within 200 feet.) <br /> {� <br /> Number of living units: Number of bedrooms }~ <br /> Character of soil to a depth of 3 feet: e <br /> SEPTIC TANK ❑ Type/Mfg. Water table depth <br /> Caci <br /> ., <br /> PKG. TREATMENT PLT. ❑ tv Z;_, No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> FEAeHING LINE ❑ No. & Length of lines jKK <br /> FILTER BEDTotal length/size 1 <br /> ❑ Distance to nearest: Wel! Foundation - <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size ti h <br /> SUMPS ❑ DiNumber <br /> f <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS p Property Line <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 /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors 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 ihall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mu call for all requir d inspections. Complete drawing on reverse side. k <br /> Signed <br /> Title: Date: -6 <br /> FOR EPARTMENT"USE ONLY'�� <br /> Application Accepted by d <br /> ! Date "' —p Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: �c <br /> ❑ Stk 411 ❑ Lodi 369-3621Manteca 823-7104 LJ Trac *� <br /> Applicant Return all copies to: Environmental Health Permit/S0 es 1601 E. Hazelton Ave., Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GK# <br /> INFO CASH RECEIVED BY . DATE PERMIT"NO. <br />+ EM 1324(REV.10!631 <br /> fH 1428 T Li <br />