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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> `1Vc 1601 E. HAZE i ON AVE„ STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> h 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> I Local Health District. <br /> 067-1 -70 S� <br /> I Job Address _4 ;- %r� City Lot Sire <br />� � r <br /> Owner's Name Address C <br /> Phone <br /> Contractor iV Address �G��� S <br /> Licertse,�� Phone� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION yam- SYSTEM REPAIP ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES !OO DISPOSAL'-F1-0;' <br /> PROP, LINE, 2-0 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> 0 Industrial pen Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Wel!Casing 5/ c <br /> �mestic/Private ❑ Gravel Pack p Tracy Type of Casing <br /> f`i Public Specifications 1�.. <br /> 04( <br /> f Ofher CI Delta Depth of Grout Seal <br /> i I Irrigation A Type o rout <br /> .. pprox. Depth I I astern dace Seal InstaEled by <br /> Repair Work Done L7.t Type of Pump H.P C <br /> 3 State Work Done <br /> Well Destruction., ❑� Well Diameter Sealing Material (top 50') <br /> . w .>. it Depth <br /> Filler Material !Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I i DES7RUCT[ON I I [No septic system permitted iF public3,5W <br /> Installation will serve: Residence_ Commercial— Otheravailable within 200 feet./Number of living units: Number of bedroomsCharacter of soil to a depth of 3 feet:SEPTIC TANK Water table depth❑ 'Type/MfgCapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposa <br /> Distance to nearest: Well Foundation Property,Line <br /> y <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED E1 Distance to nearest: Wel! Foundation <br /> t Property Line � <br /> SEEPAGE PITS I 1 Depth Size <br /> Number <br /> SUMPS 1' f LI Distance to nearest: Well Foundation - " <br /> DISPOSAL PONDS ❑ Property Line <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin ceunty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner of licensed agent's signature certifies the following: "I certify that in the performance of the work for which this petmit is issued, f 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,1 shall employ <br /> tion laws of California." p y persons subject to workman's compensa- <br /> tion <br /> applicant m t calf for all required inspectio Complete drawing on reverse side. <br /> `Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by* �f �j <br /> + Date u / Area ' <br /> Pito Grout Inspection by Date T� r <br /> Final Inspection by Date �� <br /> Additional Comments: �:� - _ Z ._._ �� ��� <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ M teca 823=7104 ❑ Tracy 835 5 <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 <br /> ' INFO CASH RECEIVED 9Y DATE PERMIT•NO. <br /> +.EH 13-24 IREV.t i k 51 <br /> EH 14-28 5 <br /> J C1 \ •E]I� t ��7 O —���]� <br />