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N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA l� <br /> Telephone (209} 466-6781 <br /> PERMIT EXPIRES 7 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 appircateon is n <br /> made in compliance 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 /> Local Health District. <br /> City Lot Size PM <br /> Job Address ,(J <br /> Al, y ddress �4 e Pfione " �6 <br /> Owner's Name <br /> F /l/ !� Address a Licens LJ Phon Q <br /> Contract <br /> BU&TYPE OF WELL/PUMP: I :!r',N�WELL LJ [11VELL REPLACEMENT DESTRUCTI❑ •:� <br /> f PUMP INSTALLATION CTSYSTEM REPAIR ❑, OTHER ❑ <br /> OP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES»--- <br /> LL EL <br /> OTHER WL i PkTSISUMPS <br /> FOUNDATION AGRIC <br /> INTENDED USE TYPE OF WELL LEM AREA CONSTRUCTION SPECIFICATIONS, <br /> ❑ industrial ❑ Ope om ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing + Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ` Type of Grout <br /> ❑ Irriga ' lApprox. Depth ❑ Eastern Surface Seal Installed by <br /> Re r Work Done 1:1Type of Pump H.P. — State Work Done <br /> .�Sealin Material-Ito 50=)--, --- f <br /> ell Destruction ❑ Well Diameter - 9- P- � r 4 <br /> Depth t Filler Material (Below 501 , <br /> TYPE OF SEPTIC WORK:. NEW INSTALLATION 0 REPAIR/ADDITION ❑ DESTRUCTION o septic system permitted,if'public sewer is <br /> i vailable within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other j <br /> V: <br /> I Number of living units: ° Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth �` t <br /> Capacity No. Compartments <br /> SEPTIC TANK El Type)Mfg � <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> s <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines I Total length/size <br /> FILTER BED ❑ Distance to nearest: Well + Foundation Property Line <br /> l { I <br /> SEEPAGE PITS ❑ Depth Size Number s <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <br /> 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 Dk"strict" <br /> Home owner or licensed agent's signature certifies.the+following: `'l 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 sdbject to workman's compensation laws of California." Contractor's hiring or subcontracting signature <br /> i 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 st cell for all re it ins ctions. Complete drawing on reverse side. <br /> Signrd <br /> Title: I Date: ' <br /> FOR DEPARTMENT USE ONLY <br /> Ap d by Date J rn <br /> Pit or Grout Inspection by Date Final Inspection by ," ' � Date��� q <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK Fi RECEIVED BY DATE PPERM`19T NO. <br /> INFO 5, <br /> + EH 3-24(REV.1/85) <br /> EH 1426 <br />