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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE;_i ON AVE., STOCKTON, CA <br /> Telephone (209) 466_6781 <br /> PERMIT EXPIRES 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 /> 4 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' „_tl <br /> 2 <br /> / k <br /> Job Address � q <br /> Ci t m Lot Size d PM <br /> Owner's Name Address — <br /> ' e <br /> t Contracto <br /> Address e N Phon <br /> TYPE OF WELL/PUMP: NEW WELL <br /> WELL REPLACEMENT ❑ � DESTRUCT(O <br /> ' PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE <br /> DIST4IVCE TO NEAREST: SEPTIC TANK f'd�ei► o SEWER LINESDISPOSAL FLD. PROP. LINE 4 <br /> FOUNDATION— AGRICULTURE WELL <br /> OTHER WELL PiTS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial "penBhttom L7 Manteca Dia. of Well Excavation / �S <br /> om stic/Private ❑ Gravel Pack ❑ Tracy T Dia, of Well Casing <br /> ❑ Public Ty of Casing Specifications lO (a ed , <br /> ❑ Other � ❑ Delta Depth of Grout Seal � d <br /> EJ Irrigation ' Ty <br /> of t <br /> �Approx. Depth ❑ astern S f e Seal installed by <br /> Repair Work Done ❑ Type of Pump C H.P, . <br /> Well Destruction Ll Well Diameter <br /> State Work Done y <br /> Sealing Material (top 50'1 N <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE_PAIR/ADDITION-❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Oth <br /> available within 200 feet.) <br /> er <br /> EI Number of living units: Number of bedrooms ' - <br /> k Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg <br /> PKG. TREATMENT PLT, ❑ Capacity No. Compartments <br /> i- <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> �. Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' - r <br /> FILTER BED ❑ Total length/size <br /> Distance-tope Well <br /> Foundation Property Line <br /> SEEPAGE PITS ❑ Depth . Size I <br /> } Number <br /> SUMPS <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS F1Property Line <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 permitis 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, I shall employ persons subject to workman's compensa- : <br /> tion laws of California." <br /> ------------------ <br /> The applicant must all for all required inspections. C mplete drawing on reverse side. <br /> Signed <br /> Title:— <br /> Date: � <br /> O DEPARTMENT USE ONLY k <br /> Application Accepted y Date i�'.J—�7 d <br /> Area <br /> Pitoor, . Date �i 1 �� <br /> Final Inspection by Date 7 <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. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> N. <br /> FEE AMOUNT DUE AMOUNT REMITTED K <br /> INFO RECEiVED,13 EDATE PERMIT NO. <br /> 1 <br /> + EH -241REV.7/e5) v\ a <br /> •EH 14-28 <br />