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r= <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA (gs <br /> , <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t (Complete in Triplicate) A <br /> EAL,TH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the w§t�t,F,y Qn'',esc1 T +s a'lication is <br /> App �" n Joaquin <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wevpump and the Ru es 2F&P 4 <br /> Local Health District. <br /> d <br /> Job Address <br /> City Lot Size PM <br /> Ph <br /> ¢ <br /> Phone/-/4 <br /> Owner's Name �OD <br /> Addres � <br /> j , - <br /> Contractor �-✓ dress V License NoJ& Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION..❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL'FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ElIndustrial*-- =-❑•Open>Bottom- ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> p.0omestic/Private C1 Gravel Pack ❑ Type of Casing 9 Specifications <br /> {'l Public s <br /> n Other f ;_ F Delta Depth of Grout Seal Type of Grout _ <br /> „ <br /> I l Irrigation —..Approx.f Dept_�l II Eastern �S rface Seal Installed by <br /> Repairi Work Done R' Type of Pump . ` H•P- State Work Done <br /> try <br /> .. Well Destruction t ❑ Well Diameter Sealing Material Stop 50'1 — <br /> Depth Filler Material {Below 50') J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I 1 (No septic system permitted if'public sewer is <br /> _ available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other 9 <br /> If � <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK LJ TypelMi! ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal - <br /> Distance to nearest: Well Foundation aP-rn a Line <br /> i LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance_to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS D Distance to nearest: Well 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 Di1trict. <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." j <br /> The applicant t call f r all required inspections. Complete drawing on reverse side. <br /> Signed X <br /> ✓j le: Date: <br /> FORD ARTMENT USE ONLY <br /> Date 'Area 6 _ <br /> Application Accepted by r9 9�- r� w <br /> Pit or Grout Inspection by Dated Final Inspection by 1 Date amu` �- <br /> i Additional Comments: -, <br /> > ❑ Stk 466-6781 D-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, Stk., CA 95201 w <br /> FEE AMOUNT DUE AMOUNT REMITTEDCASH RECEIVED BY DATE PERMIT tJO. <br /> INFO <br /> +.EH 13-24 iREV.1 51 <br /> EH 14-20 <br />