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- APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ,A <br /> - N"' � tis <br /> Job Address S Y0f&JJ 14-00 I • t City Lot Size PM \*' <br /> Owner's Nam r Address Phone <br /> Contractor Q§LAddress &Ar _Lic_ense No. _ Ph.1ne <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT T DESTRUCTION <br /> STAL341f -- .`^SYSTEM cPAM '-'+,=r+�--- .�- F.F�-Lti-:.w.-��.,.r�--�,..� a...M...,�. <br /> VDISTANCE TO NEAREST: SEPTIC TANK R LINES �—eI�FOSAL FLD INE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ( y, <br /> INTENDED USE TYPf OF WELL PROBLEM AREA CONSTRUCTION SPECIFir_ATj_gW.9 # <br /> ❑ Industrial pen Botto^ ❑ Manteca Dia. of Well Excavation 1W Dia. of Weil Casingl;E i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public n Other Ll Delta Depth of Grout Seal { Type of Grout A ZM . <br /> I ngation __ Approx. DeAh ( 1 pastern Surface Seal Installed by r <br /> Repair Work Done ❑ Type of Pump P. _ State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 C <br /> Q" <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION E I (No septic system permit if public sewer is <br /> available within 200 feet.) �" <br /> Installation will serve. Residence— Commercial Other �v <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: A Water table depth C . <br /> SEPTIC TANK ❑ T <br /> ype/Mfg Capacity 3 No. Compartments _ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> • <br /> ,r <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation_ Property Line r <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 Dtiltrict. I 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." <br /> The applicant m call for all aquir specti s. Complete drawing on r rse Sid <br /> Signed XTitle: Date: J"X0 <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by 11 rr Date Area l <br /> Pit or ro Inspection by Date Final Inspection bA 1 �"'r� Date <br /> fir' <br /> Additional Comments: fi (t <br /> ❑ Stk 466-67$1- ❑ Lodi 359-3621.._ _ -•©-Manteca 823-7104 ©Tracy- t33b-6385 - -- 'w `E�1�n°k44 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ava., P.O. Box 2009, Stk., CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED 'CK JI RECEIVED BY DATE PERM3T'NO. VV <br /> INFO CASH <br /> ♦ EH 1124(REV.i i H 51 /0 <br /> EH 14-28 o_q3 a <br />