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APPLICATION .FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA � <br /> 'Telephone (209) 466-6781 <br /> No <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> v,.�'I �''��1F �. :.(Complete in Triplicate] t. tJe(5,y <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the kel aAplic <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 —!:P e2 city ± Lot Size PM 1 <br /> Owner's Name �/ " r �/ t � G" Address L �s►a? Phonehy <br /> "i <br /> 1 i <br /> Contactorr,► Address License No. Phone_ w <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �J11 i <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR-LI –'�""' OTHER ❑ Qj i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES y DISPOSAL FLD. PROP. LINE P <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 <br /> ❑ Public ❑ Other 'f ❑ Delta Depth of Grout Seal r Type of Grout <br /> ❑ Irrigation --Approx. Depth f ❑ Eastern Surface-Seal Installed by- - t <br /> Repair Work Done ❑ ! Type of Pump H.P. P State Work Done <br /> Well Destruction. ❑ .I Well Diameter' Sealing Material Itop 50'I <br /> Depth Filler-Material iBelow:501."^= <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑, DESTRUCTION iNo septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other i <br /> Number of living units: Number of bedrooms <br /> a <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 r Total length/size <br /> .FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> l <br /> SEEPAGE PITS ❑ Depth Size r Number 1 <br /> SUMPS Cl Distance to nearest: v Well Foundation Property Line f <br /> DISPOSAL PONDS ❑ i <br /> 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. 4 . <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 became 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 ca 4'red ins ions. Complete drawing on reverse side. € <br /> s <br /> Signed Title: Date: <br /> i <br /> OR DEPARTMENT USE ONLY d� / <br /> Application Accepted by 1 Date �+ Area v 3 <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: W` 3 <br /> ❑ Stk 466-6781 El Lodi 369-3621 ❑ Manteca 823-7104 E)'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 /> FEEk <br /> INFO 'AMOUNT DUE AMOUNT REMITTED CXCA V RECEIVED 9y ' DATE PERMIT'NO. <br /> + EH'13-24(REV.e/x5) "' Q <br />