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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 /> 1PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> l[ (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described.This application is <br /> made in compliance with San Joaquin County Ordinance No-549 for sewage or No-1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District- _J 1.U�# / 5df <br /> J��J J! 7. tc' <br /> Lot PM <br /> Srze <br /> Job Address �" City <br /> Owner's Name <br /> `j' i 176 Address Phone <br /> �4/ �_ a�� Phone j <br /> Contractor <br /> Address� L.icense No. <br /> TYPE OF WELL/PUMP: J NEW WELL El WELL REPLACEMENT C _DESTRUCTION u <br /> PUMP INSTALLATION 1-1SYSTEM REPAIR C OTHER ❑ <br /> DISTANCE TO NEAR TIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATI _ <br /> AGRICULTURE WELL OTHER WELL PITS/SUMPS \ <br /> INTENDED USE f TYPE OF 1NELL PROS CONSTRUCTION SPECIFICATIONS <br /> It Excavation Dia. of Well Casing (� <br /> ❑ <br /> Industrial ❑Open Bottom ❑ Manteca Specifications <br /> ❑ Domestic)Private S;� L Gravel Pack C Tracy Type of Casing__ — <br /> ❑ Public ❑ Other <br /> Q Deka Depth of Grout Seat of Grout <br /> ❑ irrigation ---Approx. Depth ❑ Eastern Surface Seal Instaled by _ <br /> ` H.P. State Work Done <br /> Repair Work Done L9 Type of Pump <br /> Well Destruction Well Diameter Seating Material {top 501 <br /> Depth 1 Filler Material (Below 501 i <br /> TYPE OF SEPTIC WORK: NEW INN STALLATIOREPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence. Commercial-._ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet:) _Capacity d NoCompartments-- <br /> SEPTIC TANK ETypelMf9 � Method of Disposal <br /> P • <br /> KG.17R�ATMEN7PLT:J� //..r�,,� <br /> Distance to nearest: Well' <br /> FoGndation_l 6 lar Property Line <br /> �y ie 7- Total length/size <br /> LEACHING LINE T No. & Length of lines .' J <br /> fiLTER BED ❑ Distance to nearest: Well Foundation^ fir Property Line �G2 'fir <br /> t �. <br /> Size ~ - Number <br /> SEEPAGE PITS J Depth Property Line <br /> SUMPS C Distance to newest: Well - _ FoundaTion_ r <br /> DISPOSAL PONDS , I � <br /> hereby certify that 1 have prepared this a1p0lication and that the work tnnlI be done_ in accordance with San Joaquin-county ordinances,state laws, and <br /> I rules and regulations of the San.Joaquin Local Health District' <br /> I Home owner or licensed ageni's signatore•certifias the following: ''I certify that in the performance the work for which this.per sub-contractingN or traced. I shah not <br /> employ any person.in such manner as to become subject to workman's compensation laws of Cslifomia."Contract stsisub act to wdrkmas ompensa <br /> certifies the following: "I certify that in the performance of the work for which this.perrnit is issued,I shall employ pe 1 <br /> tion laws of California." <br /> ' i late drawin $n reverse side. <br /> The applicant must call for all quired inspections. Comp ,9�. <br /> Date;., <br /> Signed <br /> -� FOR DEPARTMENT USt ONLY'. <br /> Da ' Area <br /> j' "" '°..�-•� te _ <br /> Application Accepted by <br /> ate <br /> l <br /> final Inspection by D <br /> Pit or Grout Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 C Manteca 823-7104 C Tracy 835��385 <br /> Applicant- Retum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave-, P.O. box 200-- Stk., CA 95201 <br /> 1' GK t x-• _- - <br /> ff <br /> A�iiSUPIT DUE" "AXIOl�PT1 REfW1TTED GASH RECEI`!ED BY DATE�� -PERMkT NO <br /> EH 13-24(REV.+;BSS <br /> EH 1426 - - - <br /> 1 - - -- <br />