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APPLICATION FOR PERMIT <br /> I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CAS <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDt <br /> C—"l� <br /> dComplete in Triplicate) C—" <br /> I 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 /> I made in compliance with San Joaquin C+unty Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,I <br /> l <br /> Job Address City Lot Size PM <br /> Owner's Name Address hone <br /> 4ft <br /> Contractor 10' <br /> 4" . )'M�JrW Address * License No. <br /> l�_Phone <br /> tGt3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑„ _ OTHER'❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKh <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> f FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE STYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> Cl Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack _ LJ Tracy Type of Casin p <br /> 1 i � -- - g Specifications <br /> f'1 Public t i Orher r C1 Delta Surface Seal Installed ed bDepth of Grout Seal r . <br /> I I Irrigation }- + .Approx-- epth I I Eastern Type of Grout' <br /> y a <br /> Repair Work Done ❑ Type of Pumpt H-.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ! <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I ULb I HUCTiONX INo septic system permitted if n <br /> 1 available within.200 feet.) public sewer is <br /> Installation will serve: Residence— Commercial— Other w <br /> Number of living units: Number of bedrooms + <br /> Character of soil to a depth of 3 feet: ' f Water table depth <br /> SEPTIC TANK EJType/Mfg I Ca acit p. <br /> 1 s P Y No. Compartments <br /> PKG. TREATMENT PLT. ❑ I <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ! <br /> LEACHING LINE ❑ No. & Length of lines Total length/size r I <br /> FILTER BED ❑ Distance toInearest: Well Foundation Property Line t <br /> II Y <br /> SEEPAGE PITS l I Depth I! Sizer <br /> Number <br /> SUMPS L-i Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ P , <br /> I hereby certify that I have prepared this application and that the work wil <br /> rules and regulations of the San Joaquin Local Health DiMrict. l be done ii accordance With Joaquin county ordinances, state laws, and <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." I <br /> The applicant must cap for all require s ctions. Complete drawing on reversVide. <br /> 4 <br /> Signed X Title: i <br /> Date: <br /> USE ONLYApplication Accepted by4,_��� ART�ME <br /> Date <br /> _ Area <br /> Pit or Grout Inspection by Data Final Inspection by i <br /> Date ; <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUEAMOUNT REMITTED �K <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> EH 1428 <br /> _ /] Q <br /> + EH 14-24(REV.i i H 5) 3 r(1`D 23, 06 � J '% T� av �� <br /> f"- l l <br /> I <br />