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APPLICATION FO�i PERMIT <br /> III <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 011 TOCKTON, CA <br /> Telephone (209) 1466-6781 <br /> PERMIT EXPIRES I 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 Not'1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. H <br /> �7�• <br /> Job Address City S/ C�G fit Size /oO� 1 a o PM <br /> Owner's Name 2R 9?.� /�S go c! fAf A Address �/ / ✓ , r /�,1 �P� Phone0>r <br /> <2 <br /> i <br /> Contractor Address ! License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM(REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NE SEPTIC TANK SEWER LINES �� DISPOSAL FLD. PROP. LINE <br /> FOUN AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROB CONSTRUCTION SPECIFICATIONS <br /> i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca 7De:pthof <br /> Excavation Dia. of Well Casing l <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ng Specifications l <br /> ❑ Public ❑ Other ❑ Delta out Seal Type of Grout <br /> ❑ Irrigation. ----Approx. Depth ❑ Eastern Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (BefoJ 501 <br /> TYPE OF SEPTIC WORK: , NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) l/ <br /> Installation will serve: Residence_ Commercial_ Other (j <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: + Water table depth, <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> Distance to nearest: Well Foundation Property Line <br /> I� <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> IM Il <br /> SEEPAGE PITS ❑ Depth Size Number 1 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ N I <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: "I certify that inithe 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."Contractoes 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." 'I 1 <br /> The applicant must call for all required ins t, s Complete drawing on reverse`11.side. <br /> Signed X. mr�itle: 7 <br /> �'�'� � Date: �fl� <br /> FOR EPARTMENT USE ONLY 1 <br /> Application Accepted by Date 2'_2­5 Area 7 p <br /> Pit or Grout Inspection by ZZ Date __ _ Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK Ot RECEIVED BY DATE PERMIT'NO. <br /> + EH13-24(REV <br /> .3/H51 �` <br /> EH 14M28 I <br />