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APPLICATION FOR PERMIT <br /> 1 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f 1601 E. HAZEL—1 ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ; <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` <br />> (Complete in Triplicate) <br /> i hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described.This application is <br /> Application incs y San Joaquin <br /> ode in compliance with San Joaquin County Ordinance No.549 forsewage or No. 1862 for well/pump and the Rules and Regulations of the q <br /> Local Health District. <br /> Job Address ` City <br /> Owner's Name ig <br /> Address APO !K �Td .- Phone 29 <br /> ®v <br /> 1 Contractor's NamNo. i " " Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ Q <br /> PUMP INSTALLATION 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 TYIPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION li S <br /> ll ❑ Industrial ,fin Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> mea is/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑;Delta Depth of Grout Seal <br /> C T o <br /> �" ❑ Irrigation � (�+pprox. Depth ❑Eastern Su Seal Installed by <br /> Repair Work Done ❑ Type of Pump a H.P._ <br /> F— <br /> State Work Done a <br /> Well Destruction ❑ Well,�Diameter °Sealing Material Itop 501 <br /> Depth Filler Material I Below-50')., <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ lNo septic system permitted if public sewer is 4- <br /> i. available within 200 feet.), rr <br /> � �lnstallation" n will serve: Residence— Comme cial �Other <br /> Number of living units: A 11'\ Numbef of.bedrooms K *� F. ;•t= <br /> * Character of soil to a depth of i3�feet: - - ` — '= m Water <br /> y <br /> SEPTIC TANK ❑ Type/Mfg Capacity {`'Nb-Compartments <br /> PKG. TREATMENT PLT. ❑ I Method of Disposal <br /> istance to nearest: Well Foundation Property Line ` <br /> IF <br /> e <br /> { LEACHING LINE 13 No. lenth/sizNo. & Length of lines g F <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS -1 `Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El .11 <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 Districts <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."Contractoa's hiring or sub contracting signature r <br /> I 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-;f <br /> tion laws of California." <br /> The applicant m t cal or alLrequired inspections. Com l drawing on reverse side. <br /> i SignedITitle: Date: <br /> F <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date - Area <br /> Pit or Grout Inspection by Date k-� Final Inspection by Date <br /> Additional Comments: <br /> I ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED,.BY DATE PERMIT"N0. <br /> INFO <br /> + EH 1324 IREV.1010 III <br /> EH 14-20 - <br />