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APPLICATION FOR PERMIT <br /> dr. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELiON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _ ,,,'c_ <br /> 1 (Complete in Triplicate) y .. <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. " , <br /> City F tLot-Size PM <br /> Job Address - <br /> Owner's Name - Address Phone <br /> t <br /> Contractor j dress License No. Phone <br /> ljj" l�T <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ _- DESTRUCTION ❑ i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. i PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHERfWELL—:= t PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS' j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of'Casing r"— `"—" Specifications <br /> ❑ Public ❑ Other t ❑ Delta Depth of Grout Seal Type of Grout <br /> I ❑ Irrigation ---Approx. Depth ❑ Eastern SurfacetSeal Installed by. k <br /> Repair Work Done ❑ i Type of Pump H.P. State Work Done ` <br /> Well Destruction ❑ -<Well Diameter �. Sealing Material (top 501 ` i 4?­15 _kN <br /> Depths- Filler Material (Belo 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION r DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence_ CommerQq <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: r r. r ` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg ;" i � Capacity--L— No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal <br /> Distance-46-2o nearest: Well Foundations`- Property Line n` <br /> � :" <br /> LEACHING LINE'* T No. & Length of lines ° w Tofal length/size <br /> FILTER BED ❑ Distance to nearest: f 5V'Uell run_ tt,6r, _` Property-Linezv 0 <br /> 10 <br /> h SEEPAGE PITS Depth ^ Size #Number <br /> n ; <br /> SUMPS ❑ Distance to nearest`. Well Foundation Property Line <br /> _ <br /> DISPOSAL PONDS <br /> VA �- �-,j-.� t <br /> � El .. � --- - -- <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. '7 <br /> i 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:"'!certify that in the performance of the work for which Is' permit is.issued, I shall employ persons subject to workman's-compensa�..._..�� <br /> tion laws of California.",—...The applicant t or, equ' i ctions. Complet yawing on reverisq side. <br /> i .Signed Title: -- - Date: <br /> { FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date rea <br /> Pit or Grout Inspection by �. � Dat�e,�,.,j Final Inspection by. - Date� <br /> A ditional Comments: <br /> 9(Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 623-7104 ❑ 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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE p PERMIT'NN`O. <br /> + EH 13-24 1REV.t/957 <br /> EH 14-26 3 <br />