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j APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i 1601 E. HAZEL T ON AVE., STOCKTON, CA ' <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED APR 9 mo <br /> (Complete in Triplicate) EMIRONMEatfT <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hweiond scnpq)14ijhk dn`is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules atrIA-r bb" _p� �i'�EntJoaquin <br /> Local Health District. <br /> ���� ffac <br /> Job Address � +� [�11k4Q City Pe+ Lot Size PM <br /> Owner's Name c Address ; Phone ! <br /> Contractor - ' 144.) Address/ enylp -2A Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL 14 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑t <br /> DISTANCE TO NEAREST:�SEPTIC TANK.�� '� SEWER LINES—* _- " - DISPOSAL-FL-D-= pROP....LINE; <br /> c - <br /> FOUNDATION r AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> a <br /> INTENDED USE TYPE OF ELL CO <br /> `'` PROBLEM? REA NST <br /> WRUCTION'SPECIFICATIONS <br /> ❑ Industrial ED-Open Bottom ❑ Manteca Dia.-of-Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy ,.. ri r Type.of.:Casing t. Specifications <br /> f'l Public 171-Other _ ❑ Delta _.-.De pth of.Grout Seal, Type of Grout <br /> I I Irrigation _-_Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑. Type of Pump �� H.R? r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material .(top 50') _- <br /> Depth ^' Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet,) 'Sl- <br /> Installation will serve: Residence Commercial Other 1 <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. I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ' Well ­41 <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> 9 Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth -.y Size <br /> _ Number <br /> SUMPS ❑ <br /> is to nearestT '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 District. <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 workrflan'S compensation-laws of-Catifornia."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 must Ii f 11 required inspections. Complete drawing on re rse si e. <br /> Signed X + Title:. i <br /> Date: <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by Date !'v rea00 <br /> �� <br /> Pit or Grout inspection by Data Final Inspection by Date s <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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, Silk., CA 95201 <br /> a <br /> FEE AMOUNT DUE AMOUNTREMITTED <br /> INFO C RECEIVED BY DATE PERMIT NO. <br /> ..EH 1 -28[REV.iinsr 7i 1 <br /> EH 14-2d Y <br />