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f <br /> APPLICATION FOR PERMIT } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.,_STOCKTON, CA <br /> 1 <br /> a' phone 12091 466-6781 <br /> PERMIT -fX',_-TRES 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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. q <br /> Job4AddressZ33 City Lot Size A2 Z I-- PM <br /> Owner's Name Address es Phone —Wo <br /> Contractor r/Prt`S Address <br /> ��(LLicense No6 ,7"__Phone d <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION O - <br /> " PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> s <br /> DISTANCE TO NEAREST: SEPTIC TANK f.?ra f SEWER LINES D�,SP,�OSAL FLO. PROP. LINE <br /> ', FOUNDATION AGRICULTURE WELL OTHER WELL - PITS/SUMPS /�/4- <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El-industrial ❑ Open Bottom El Manteca Dia- of Well Excavation Dia. of Well Casing <br /> *omestic/Private KGravel Pack ❑ Tracy Type of Casing Specifications A40 <br /> 1'1 Publicf r ❑ Other ❑ Delta Depth of Grout SealllyrlrAI Type of Grout . <br /> 1 I Irrigation—_.._— .-._Approx. Depth I I Eastern " Surface Seal installed.by. 5_10- _ <br /> Repair Work Done ElType of Pump .__ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material-(top 501 <br /> Depth Filler Material ,f8elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I l DESTRUCTION l 1 INo septic system permitted if public sewer is <br /> available within 200 feet.) (� <br /> Installation will serve: Residence_ Commercial _ Other <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 1 <br /> BLEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1­6pth_ ` a "Siie "��` -"" '"'� =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, l shall not <br /> employ any person in such manner as to become subject to workman's compensation taws 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 plete drawing on reverse side. <br /> — I <br /> Signed X Title: Date: f <br /> . l <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by M Date/1_--L S Area <br /> Pitor Grout inspection by Date /j� Final Inspection by n Date <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. Hazeltorf Ave., P.O. Box 2009, Stk., CA 95201 I <br /> a <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> CK <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> r <br /> �.EH13-24(REV.rias) <br /> EH 14-26 J <br /> J <br />