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�* APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 + <br /> I 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 /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. i <br /> jlb <br /> Job Address 1t✓' City` In,Size PM <br /> „ Owner's Name Address Phone -1 " <br /> I <br /> Contractor Address License No. Phone_ <br /> 7 PE OF WELL/PUMP:._ _,,NEW.WELL.❑ WELL REPLACEMENT ❑_ DESTRUCTION ❑ ' <br /> PUMP INSTALLATIN ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA.—CONSTRUCTION SPECIFICATIONS <br /> El industrial El Open Bottom 11 Manteca iiia,—of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofsing Specifications <br /> f1 Public F Other ❑ Delta Depth of GroT eal Type of Grout <br /> I I Irrigation _:.Approx. IDepth __I <br /> E6-5 am Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter r Sealing Material )top 50'I <br /> Depth `- - Filler Material {Below 50')., <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION l 1 DESTRUCTION Wo septic system permitted if public sewer is }� <br /> - available within 200 feet.) `+1 <br /> 1. <br /> Installation will serve: Resideriice_f Commercial_ 'Other <br /> Number of living units: dumber of bedrooms <br /> S <br /> Character of soil to a depth of 3 feet:, t Water table depth <br /> SEPTIC TANK ❑ 'T.ype/Mfg 4 '' -Capacity sNo. Compartments <br /> PKG. TREATMENT PLT. ❑ F rMethod of Disposal <br /> F <br /> Distance to nearest: Well Foundation --Property Line <br /> LEACHING LINE ❑ No.&•L-ength of-lines Y Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS' l 1 Depth 1 Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ . 4 --^___- Y- a - _ y.-�..�-.�. <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 Jaws, 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." 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." <br /> The applicant ured inspections. Complete drawing on reverse side. <br /> Signed X_ m <br /> A Ilk Title: ,�� �f _ Date: <br /> FOR DEPARTMENT USE ONLY <br /> VIM ,{ <br /> Application Accepted byU111% pate _ �rea I <br /> Pit or Grout Inspection by Date, "nal Inspection by Date + <br /> Additional Comments: AD <br /> (� <br /> XStk 466-6781 ❑ Lodi 1 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> plicant - Return at[copies to: Environmental Health Permit/Services 1601,.E. Hazelton Ave., P.O.' Box 2009, Stk., CA 95201• y <br /> INFO AMOUNT DUE AMOUNT REMITTED OK 11 RECEIVED BY DATE PERMIT'AlD.FCE I. <br /> + twsFr <br /> EH 1324(REV.1/9 51 Uv /� y <br /> EH 14-28 ". � -. �J4 Eo � 1 Ill ) r`32 <br />