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APPLICATION,FOR PERMIT r� <br /> SAN JOAQUIN LOCAL-HEALTH DISTRICT A { <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 /> Local Health District. <br /> Job Address T / _ 1-r 7' ! City . _...._ Lot Size&Q.X 7 PM <br /> Owner's Name _ G Address G Q Phone <br /> yi <br /> Contractor Address License No. Phone I <br /> TYPE OF WELL/PUMP: 'NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ -� <br /> i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD.. E <br /> FOUNDATION AGRICULTURE WELL _OY- W16__ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 11 Gravel Pack Tracy Type of Casing 9 Specifications <br /> ❑ Public ❑ Outhjer171 Delta Depth of Grout Seal Type of Grout <br /> ❑ Irriga�DLI <br /> �Approx. Depth ❑ Eastern Surface Seal Installed b <br /> Repair ype of Pump H.P. �_t State Work Done <br /> Well ell Diameter Sealing Material (top 501 .. <br /> Depth Filler Material (Belc,W-50.1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION'O(No septic system permitted if public sewer is <br /> ..available-within-200-feet.► <br /> Installation will serve: Residence_ Commercial Other T <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 <br /> PKG. TREATMENT PLT. ❑ '� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line - <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> f FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number " <br /> SUMPS O- Distance to nearest: Well -Foundation-=7- �•� Property-Line <br /> DISPOSAL PONDS ❑ t <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 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 must call for all required inspections. Co plate drawing on reverse side. <br /> Signed X Title: Date: - <br /> FOR EPARTMENT USE ONLY <br /> F Application Accepted by Date Area <br /> Pit or Grout Inspection b Date Final inspection by Date <br /> t <br /> Additional Comments: ��Vy�� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑.Manteca - 104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE P'^ERMIT•/NO. <br /> + EH I 13-24(REV,i/rss}EH 1428 � � ...✓�? - _- -- ,. , <br /> i <br />