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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephoohe (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> 100 <br /> ice, <br /> Job Address <br /> City Lot Size PM <br /> Owner's Name *' x r ss Phon <br /> 0 ell <br /> r Contractor o License No� Phone t-r <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> t <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES.' DISPOSAL FLD. PROP. LAVE <br /> — FOUNDATION - AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> f ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public Cl Other ❑ Delta_ Depth of Grout Seal _ Type of Grout _ <br /> I I Irrigation <br /> —.-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair,Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> r <br /> Depth Filler Material {Belo <br /> I TYPE OF SEPTIC WORK: NEW INSTALL ON 11 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is g <br /> � available within 200 feet.) <br /> Installation will serve: Res'dence Commercial Other <br /> Number of living units: Number of bedrooms .--_ <br /> Character of soil to a depth of 3-feet Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Dispo l <br /> ° Distance to nearest: Well w-4 Foundation Prcperty.Line _— <br /> LEACHING LINE ❑ No. & Length of linesTotal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 3 Z2 Property Line <br /> SEEPAGE PITS 11 Dept 1. ize N ber <br /> UMP L] Distance to nearest: Wel!—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,' and <br /> rules and regulations of the San Joaquin Local Health District. i <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 become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the followings'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 /> h The applicantingst c for at required i pe tions. Complete wing onyevq"sse'side. <br /> Signed X Titfe; �L��yy�IJJ ` ! Date: t✓ <br /> b FOR DEP RTMENT USE ONLY .� <br /> Application Accepted by ' Date Area <br /> ' Pit or Grout Inspection by } Date Final Inspection by Date <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.O. Box 2009, Stk., CA 95201 <br />� t <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CA&H RECEIVED BY DATE PERMI7'NO. <br /> +.EH 13.24(REV.t i 115) l /�-y <br /> ... ,EH.t4 28 -tom .. _ ! 7731 � <br />