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a <br />�. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> {Complete in Triplicate} <br /> a� <br /> ,il <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 /> I made in compliance with San Jbequin 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 /> F'I 1 <br /> ! City Lot Size PM <br /> Job Address f H `" <br /> Owner's Name <br /> Address Phone \ <br /> —y t� License No. ZIK;_e Phone911-3)-32� <br /> Contractor's Name / V <br /> TYPE OF WELL/PUMP: NEW WELL�$ +WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> OTHER ElPUMP INSTALLATON SYSTEREPA4R © <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD�+n�� PROP. LINE o� <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 7 C. Dia. of Well Casing <br /> T of Casing Specifications <br /> � •� <br /> Domestic/Private 0 Gravel Pack ❑ Tracy Type _ <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> El Irrigation ---Approx. Depth ❑ Eastern Surface Seal'Installed by- <br /> Type of PumpH.P. tate Wor Done <br /> I Repair Work Done ❑ <br /> > Well Destruction LlWell Diameter �. Sealing Material (top 50'1 a <br /> Depth Filler Material {Below 501 - <br /> j T OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will Residence_ Commercial_ Other <br /> Number of living units: ber 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 o ion Property Line .77- <br /> LEACHING LINE ❑ No. & Length of lines Y <br /> To th/siie� .l <br /> i. FILTER BED ❑ Distance to nearest: Well Foundation Pro Line - <br /> i <br /> ry <br /> SEEPAGE PITS ❑ Depth Size Number t- _� ,. <br /> l .-„,SUMPS � I] '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, an <br /> rules and regulations of the San Joaquin Local Health District. <br /> f. <br /> Home owner or licensed agent's signature certifies the following: "I cerfrfy 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.”Contractors 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 subj6ct.to workman's compensa- <br /> tion laws of CaliforNa' ::-r <br /> The applicant must call for all-required:inspections. Complete drawing on reverse side. <br /> Si ned Title: Date: <br /> g <br /> USE ONLY FOR DEPARTMENT <br /> Date <br /> Application Acceptedµ 1 Q 4 <br /> Pit Grou nspection by, <br /> Date Q v'A0 Final Inspection by G U,, �� Data 1� <br /> Additional Comments: A+ <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 C] Tracy 8355-6385 <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 CK RECEIVED BY DATE PERMIT`NO: <br /> INFO <br /> +EH 13-24(REV.101831 _ <br /> CASH <br /> _ m <br /> �� <br /> EH 14-28 <br />