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APPLICATION FOR PERMIT r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ��'� 3U —2 <br /> 1601 E. HAZE T 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 /> 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 Addres d City Lot Size PM <br /> Owner's Name- Address 2� Phone` 213 d <br /> _...�� <br /> Contractor' y" ress <br /> License Ns 4 2� �, Phone <br /> x .TYPE OF WELL/PUMP: NEW WELD WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> - k <br /> PUMP INSTALLATION 5K SYSTEM REPAIR- ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / SEWER LINES DISPOSAL FLD. PROP.'LINE <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 Excavatio Dia. of Well Casing <br /> -Gravel Pack ❑ Tracy Type of Casing Specifications <br /> P <br /> FI I Public n Other F1 Delta Depth of Grout Seal Type of Grout _ <br /> Irrigation _-Approx. Dep i I Eastern Surface Seal installed by <br /> Repair Work Done 0 Type pf Pump x H.P. I State Work Done DEC <br /> Well Destruction ❑ Well Diameter f Sealing Material (top 50') <br /> Depth it Filler Material (Below 50') " <br /> TYPE OF SEPTIC WORK: NFVf INSTAL'LATION..1:1 REPAIR/ADDITION i I DESTRUCTION I. I (No septic system permitted if public sewer is <br /> �- t �. available within 200 feet.I f <br /> Installation will serve: Reside: ce--_Com ercial a, <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Tye/Mfg R Capacity . No:-Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispose! M <br /> i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PETS I I Depth Size Number <br /> SUMPS C� Distance to nearest: Well FoundationProperty 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: "1 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: "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 m call or all ref inspections Complete drawing reverse side. } <br /> i Signed X Title: l 7- � <br /> Date: <br /> t FOR DEPARTMENT USE ONLY 7 <br /> Application Accepted bAby <br /> .Dates U ;" / Area-012_. <br /> Pit or Grout Inspection Dat IQ Final Inspection by Date �' �Additional Comments: tROA Al A A. U,vJZ V!i I�>' �J -e J-412 <br /> ❑ Stk 466-6781 ElLodi 369-3621 0 Manteca 823-7104 ❑ Tr cy 835-EUB5 rel✓k r dirt <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601.E. Hazelton Ave., P.O. Box 2009, Stk., CA 95291 1 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> _ <br /> +:EH 1324(REV.I/H 5) <br /> EN 14-28EV -- — 9-8 7 7 591 <br /> F' G'7 '­�-1.-- D <br />