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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E:1=HAZEL T OWIAVE., STOCKTOIV, CA <br /> Telephone {209) 466-6781. f <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate) <br /> 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 /> 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 /> made in compliance <br /> Local Health District.*,;S1rC>: <br /> iiAl d , <br /> Job Address <br /> V 1-2 aa L � - L �. City Lot Size L /�L ✓ PM <br /> ` _ Address �• 1)• ' 77 � � �� Phone <br /> 477- & <br /> Owner's Name �2 D <br /> Contractor -- - -Address ' s <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT 11 DESTRUCTION C1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> t DISPOSAL FLD. PROP. LINE <br /> r FOUNDATION AGRICULTURE WELL i OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION(SPECIFICATIONS <br /> Dia. of Well Casing <br /> ❑ Industrial -LlOpen Bottom C] Manteca Dia. of Well Excavation <br /> L1 Domestic/Private Q Gravel Pack Q Type of Casing 9 Specifications 4 <br /> Q Public <br /> I L1Other C3Delta Depth of Grout Seal Type of Grout <br /> El — <br /> IrrigationJ,pProx. Depth Ll Eastern Surface Seal Installed by <br /> H.P. <br /> State Work Done <br /> Repair Work Done Ll.. Type of Pump <br /> Well Destruction [IWell Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATtO REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system <br /> m feet rmi`ed if public sewer isavaA <br /> Installation will serve: Residence_ Commercial Other s <br /> Number of-living units: "`�' Number of bedrooms <br /> 41; r Water table depth -7 t <br /> Character of soil�to a depth of 3 feet: <br /> Capacity -- No. Compartments <br /> SEPTIC TANK �B'-Type/Mfg _ <br /> t aMethod of Disposal <br /> PKG. TREATMENT PLT. ❑ 2 Q� Property Line <br /> I �Foundation Pe Y <br /> Distance to nearest: Well <br /> L1lS�e5 A Total length/size <br /> LEACHING LINE ❑ No. & Length of lines r .���J��QI--J�r(,� <br /> FILTER BED f ❑ Distance to nearest: Well� Foundation Property Line <br /> t 11 <br /> SEEPAGE PITS Depth Size L>�Ckl � Number <br /> SUMPS ElDistance to nearest: Welt foundation Property Line <br /> DISPOSAL PONDS ? ❑ <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: that in'the performance of the wo <br /> "I certify rk for which this permit is issued, I shall not .hl <br /> mpensatiori'Iawrs of California."Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's co <br /> certifies the following:"I certify that in the performance of the work for which this'peirtlit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." :! <br /> The applicant must call for wired i specf ns. Cam eta drawing on reversside. 1 1 <br /> Title: <br /> signed _ Date: l <br /> OR-DEPARTMENT IUSE ONLY <br /> IF <br /> ^� <br /> F ! =�' Date G Area t <br /> Applidation Accepted by - I <br /> al Inspection by Date <br /> Pit r Grout Inspection by Date 7�- <br /> Additional Comments: ? <br /> --p Stk q66 6761 ❑ Lodi 369-3621 Manteca 823 7104 4 ❑ Trace 835 sie5 <br /> /. __ <br /> 4 Applrcant- Return all copies to: Environmental HealthPermitlServices 1601 E.-Haze Ave., P.O. Bax 2009, Stk., CA 96201 <br /> J<" I .� <br /> FEE AMOUNT DUEfn AMOUNT REMITTED _ -� <br /> .RECEIVED BY DATE PERMIT`NO. <br /> INFO <br /> +E14 13-241REV.1/8 sl 6 ... � a� <br /> EH 14-26 <br />