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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 /> �L 3 f yyr 1-�� <br /> (Complete i�LT�'p icat�j)G� <br /> Application is hereby Lail to he Satf Joa� Lo�ca�Hle�lttS Di%strif"t f6r a pe"rmif to st�uc6 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. O I- jfl fj . <br /> Job Address city Lot Size <br /> \ <br /> Owner's N !/ame � " ;'�Address � "ti l` ,� • Phone �j <br /> Contractor's Name License No. ` + Phone ! Q <br /> I �f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ' <br /> i, DISTANCE TO NEAREST: SEPTIC TANK. SEWER LINES DISPOSAL FLD. PROP. LINE +' <br /> -.-... <br /> FOUNDATION' 'AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy , Type of Casing Specifications W <br /> ❑ Public' ❑ Other ❑ Delta k Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work.Done ❑ Type of Pump H.P. � State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth ' Filler Material{Belo_wi50'} '' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> { <br /> available within 200_feet.! <br /> Installation will serve: Residence_ Commercial_ Other -� <br /> Number of living units: Number of be rooms <br /> t Character of soil to a depth of 3 feet: ��'yy Water table depth Q Ck <br /> l SEPTIC TANK ❑ Type/Mfg Capacity ( No. Compartments <br /> EI PKG. TREATMENT PLT. ❑ / Method o'f/Diissppsal <br /> I i Distance to nearest: Well lop Foundation Ile Property Line ._ <br /> LEACHING LINE No. & Length of lines t Total length/size <br /> R BEd ❑ distance <br /> to nearest: Well Foundation Property Line t4 D <br /> FILTER --- - <br /> SEEPAGE PITS ❑ Depth Size w Number <br /> SUMPS ❑ Distance to nearest: 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 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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The'applicant ust f all requi inspections C piete drawing on verse side. G �j <br /> M <br /> Signed ` Title: Date: <br /> Date: <br /> FOR QEPARTMENT USE ONLY f <br /> Application Accepted by Date ` Qrrea B /G <br /> Pit or Grout Inspection by / Date ' ` . Final Inspection by Date <br /> Additional Comments: b 6-C f� ij-e- <br /> 0 <br /> e❑ Stk 466-6781 - ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Returwall copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;,Stk.", CA 95201 <br /> FEE AMOUNT DUE REMITTED CASH RECEIVED By DATE PERMIT NO. <br /> a h .-.INFO .—AMOUNT <br /> +cEH 13-24 SREV.10/83) e`+ -- — - 4 �i <br /> EH 14-28 "� } <br /> A <br />