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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 c <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED Nv <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 $�-/ w' / t� `� City Lot Size PM <br /> Owner's Name Address Phone {l <br /> Contractor�. LL- Address <br /> L rise No. �Phone d S <br /> TYPE OF WELL/PUMP: NEW WELL ❑. WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> .A t FUMPtINSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK - SEWER LINES DISPOSAL FLD. PROP. LINE <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> y INTENDED USE TYPE OF WELL PROBLEM AREA CON STRUCTIONiSPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> f ❑ Domestic/Private• ❑ Gravel Pack R ❑ Tracy Type of Casing a Specifications <br /> 17 Public ❑ Other ' ❑ Delta Depth of Grout Seal Type of Grout <br /> I t Irrigation _ —.-Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑• -Type of Pump H.P. State Work Done <br /> + <br /> Well Destruction ❑ Well Diameter ` Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> I TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTION I septic system permitted if public sewer is <br /> r y available within 200 feet.) <br /> r <br /> Installation will serve: Residence___>_ Commercial_ Other <br /> Number of living units: Number of�bed�ooms <br /> k Character of soil to a depth of 3 feet: Water table depth <br /> 4 SEPTIC TANK ❑ Type/Mfg - `kms^ - Capacity w-Y No. Compartments <br /> IIF T PKG. TREATMENT PLT. ❑ Method of Disposal <br /> r _ Distance to nearest: Well Foundation # Property Line <br /> LEACHING LINE ❑ Nq: & Length of lines Total length/size <br /> a <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation I Property Line <br /> t' DISPOSAL PONDS ❑ I <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 rJoaquiri Lacal Health District ~` ' <br /> Home owner or licensed agent's signature certifies the following: "1 certify that in the performance of-tha work for.which this permit is issued, I shall not <br /> f 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 /> c s the following:-'%cer fify that in the performance of the work for which this permit is issued, I shall'ertiploy''persons subject to workman's compensa- <br /> tion la f California t <br /> The applica t st call f s. tplate drawing on re rse side. r <br /> { <br /> Sige <br /> nTitle: .. <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by w- _ - Date �s'-VC,-S'-Q Area <br /> Pit or Grout Inspection by t Date _FinalInspection by Q 4" Date <br /> ' Iditional Comments: .r <br /> 6 <br /> I �c Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑f Tracy 835-6385 <br /> t Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> /� <br /> + EH 13-24(REV.I x5) INFO 36�tic) �l � �5 -23r <br /> EH 14-2$ eJ <br />