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k <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> y 1601 E. HAZEL T ON AVE., STOCKTON, CA 111 V <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1-YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> quin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> Application is hereby made to the San Joa <br /> for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 <br /> Local Health Diss e5 rte" <br /> /� J City Lot Size PM i <br /> Job Addres ry <br /> yyyy��DD Address ` �!r —� Phone SSS <br /> ;717 <br /> Owner's Name!>>e, S� - <br /> / // Address 912 /✓ License No. 1 P Phone <br /> -D/rte <br /> ` Contractor <br /> TYPE OF WELL/PUMP: NEW WELL El REPLACEMENT 171 DESTRUCTION 13 <br /> OTHER <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR 171 <br /> DISPOSAL F.LO. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> INTENDED USE TYPE OF WELL Dia. of Well Casing <br /> ❑ Industrial 0 Open Bottom Ll Manteca Dia. of Wel{ Excavation <br /> Type of Casing Specifications <br /> L) Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout <br /> 1'1 Public ❑ Other ❑ Delta Depth of Grout Seal - <br /> I I Irrigation Approx. Depth I I Eastern Surface Seal Installed by <br /> H P State Work Done_ r <br /> Repair Work Done ❑ Type of Pump 1!1 <br /> f Well Destruction ❑. Well Diameter Sealing Material itop 50'I <br /> f Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITION l 1 DESTRUCTION aNailabpelwthin 20�fee.t.] <br /> c system red if public sewer is <br /> Installation will serve Residence_,__C — Other - I <br /> Number of living units: Number-of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> E] Method of Disposal <br /> PKC, TREATMENT PLT. <br /> Property Line <br /> Distance to neatest: Well Foundation p Y <br /> _ ` <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> rr <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property me <br /> I SEEPAGE PITS I I Depth Size Number ; <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r <br /> I hereby certify that 1 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 DRtrict. <br /> r 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 California." a <br /> must call for all required inspections. Complete drawing on reverse side. f <br /> The applicant � <br /> y Title:[r�• Date: <br /> Signed X 1 <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> F Additional Comments: / <br /> r ElStk 466-6781 El 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, Sik., CA 95201 <br /> FEE. CK RECEIVED BY GATE PERMIT'NO. <br /> AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> +.EH 13-24(REV.5 i x 5) <br /> EH 14-2a <br />