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APPLICATION FOR PERMITC r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _] <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Np Wap wwi� - <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED Nom. L. <br /> (Complete in Triplicate) 04- w5l <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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. J <br /> Job Address &A l r��1J City�� Lot Size PM t <br /> .01 <br /> Owner's Nam Address Phone,6424 <br /> s 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 NEAREST: SEPTIC TANK SEWER LINES DISPOSA PROP. LINE <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON TION SPECIFICATIONS <br /> r <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications <br /> ° ❑ Public ❑ Oth ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _.Approx, Depth I 1 Eastern Surface Saal Installed by <br /> r ork Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION l I DESTRUCTIONo septic system permitted if public sewer is <br /> I <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <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 Capacity No. Compartments 1 �' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal it <br /> Distance to nearest: Well Foundation Property Line <br /> rl \" <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well_ Foundation Property Line <br /> I <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: WeII 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, an" <br /> rules and regulations of the San Joaquin Local Health District. I� <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." n <br /> The applicant mu all for all require spe tions. omplete drawing on reverse side. <br /> f <br /> Signed e Title: Date: <br /> OIC DEPARTMENT USE ONLY Q <br /> Application Accepted by Date 1 Area <br /> Pit or Grout Inspection by Oat Final Inspection •bey ' Date I� <br /> Additional Comments: ��� <br /> 11 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 t <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 I` <br /> 115(tisS 4-r- iAs qAd <br /> FEE <br /> INFO A OUNT DUE AMOUNT REMITTED CASH RECEIVED 8Y DATE PERMIT"NO. <br /> +.EH 13-24{REV.V H 51 <br /> EH 14-26 <br />