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APPLICATION FOR PERMIT <br /> a tSAN JOAQUIN LOCAL HEALTH DISTRICT ll <br /> ro 1601 E. HAZEL ON;AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> I <br /> Application is hereby made to the San Joaquin Local Wealth 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 Address /f fif J <br /> ' ADV I City £ PM <br /> Owner's N me 'e�7 Address Phone <br /> zN,1466-yf <br /> Contractor �� Address License y�Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L1 DESTRUCTION ❑ <br /> r <br /> 1 PUMP INSTALLATION SYSTEM'REPAIR ❑ OTHER ❑ <br /> I, DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> j FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USES j TYPE OF,WELL r <br /> PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> - <br /> ❑ Industrial "'°"�_❑ Open Bottom _-. .r❑ [blan[eca'- —�''Dia. of'Welf Excavation '" "'Dia. of Well,Casing <br /> 415"mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth bf Grout Seal Type of Grout <br /> ❑ Irrigation /_._Approx. Depth ❑ stern S� ce Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material{Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION d DESTRUCTION ❑ (No septic system permitted if public sewer is--. 9 <br /> available within 200 feet.) <br /> ' Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms , <br /> Character of soil to a depth of 3 feet: ` n Water table depth <br /> SEPTIC TANK ❑ , Type/Mfg S rapacity w No. Compartments <br /> PKG. TREATMENT PLT. El �!V Method of Disposal .� <br /> Distance to nearest: Well Foundation F Property Line <br /> E <br /> LEACHING LINE ❑ No. & Length of lines Total length/size j <br /> ( FILTER BED ❑„ Distance to nearest: Well Foundation L Property Line <br /> SEEPAGE PITS ❑ Depth Size ) Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> 1 DISPOSAL PONDS ❑ <br /> : <br /> I hereby certify that I have prepared this application and that the work will bedone in-accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of aquin Local Health.District. ', - <br /> Home owner or lice d agent's sig tura certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any pars in such manner as to become subject to workm compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fol wing:';`I certify that a performanc ti ich this Permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of alifornia.,',,;j.J % <br /> The appfrca t must a fired ins i mg- everse.sid <br /> I Signed e: _ <br /> ' 4 <br /> FO EPARTMENT USE ONLY <br /> I Application Accepted by Date Area J <br /> c <br /> i Pit or Grout Inspection y Date Final Inspection by �y�j Date <br /> - Q L �`r 11� .er1 Q. l:I cI G�^ / G GtJ t Ir rM. <br /> Additional Comments: / U <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835.6385 � e <br /> Applicant:Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> p <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. f <br /> INFO CASH <br /> + EH 13-24IREV.1/85) S.. �� 3rd S-7 <br /> EH 7426 <br />