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APPLICATION FOR PERMIT <br /> e <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67813 <br /> PERMIT EXPIRES 1YEAR 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 Address <br /> City. Lot Size PM <br /> Owner's Name ` _✓ O Address Phone <br /> Contractor <br /> )-Cllr f Address �x F1 -A+ham License No.�Phone w D <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:SEPTIC TANK SEWER LINES DISPOSAL FCD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PIT5ISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications " <br /> Fl Public Cl Other 11 Delta Depth of Grout Seal Type of Grout �Ay`11 <br /> I I Irrigation _.Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump _ H.P. _ State Work_Done <br /> Well Destruction L1 Well Diameter Sealing Material (top 501 <br /> Depth Filler Material {Below 50') ic <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION t I DESTRUCTION {No septic.system permitted if public sewer is <br /> vailable within 200 feet.) <br /> i <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ ' P^ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/siie <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r. <br /> SEEPAGE PITS I ) Depth Size _ Number <br /> SUMPS L� Distance to nearest: Well Foundation Property Line ` <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I WaXe prepared this application and that the work will be done in accordance with San Joaquin county ordinances;state laws, and <br /> 11. <br /> rules and*naef <br /> San Joaquin Local Health District. k ` = <br /> Home ownt signature certifies the following: ''I certify that iri the,performance of the work for which this permit is issued, I shall not <br /> m ner as to become subject to workman's cofripensation laws of California."'Contractor's hiring or sub-contracting signature <br /> employ ac I <br /> tfi performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> t <br /> certifies <br /> tion lawsThe applir II r quired inspections. Complete drawingon reverseon reverse sidl <br /> Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> .. <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 /> r Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazeltan Ave., P.O. Box 2009, Silk., CA 95201 <br /> r _ <br /> EEE AMOUNT DUE AMO NT REMITTED CA H RECEIVED BY DATE PERMIT'NO. <br /> INFO %%ffj��')' 11 <br /> +.EH 13-24(REV.t/X5) /� \ � 4 " �r <br /> EH 14-213 VVV <br />