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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />' 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> �Llr ,< (Complete in Triplicate) co <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 /> /I ,� <br /> Job Address �r Ci of Size PM ._ <br /> Owner's Name / M/94_d6n4ddress ►r I — Phone <br /> Contractor's NameMAtLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIOK SYSTEM REPAIR ❑ OTHER ❑ <br /> _DISTANCE TO NEAREST: SEPTIC TANK M SEWER LINES DISPOSAL FLD. , PROP. LINE <br /> r T - r- .._ <br /> FOUNDATION l AGRICULTURE WELL OTHER WELL- PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing y <br /> KDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout J <br /> ❑ Irrigation ---Approx. Deptfi Eastern Surface Seal Installed by <br /> Repair Work Done C Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 rn <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> r 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg _ Capacity No. Compartments <br /> l PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> k Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Numberh <br /> SUMPS = ❑ Distance to nearest: Well 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. <br /> that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify <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 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- <br /> tion laws of California." <br /> The applicant m call for �equiredctions. Com tete drawing on reverse 'de. <br /> I Signed &nq Title: JA Date: <br /> / FOR DEP MENT USE ONLY <br /> Application Accepted by v " Date k 7, ex Area <br /> Pit or Grout Inspection by Final Inspection by Date <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-710.4 - ❑ 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 CASH RECEIVED BY DATE PERMW'NO. <br /> INFO <br /> r EH 13-24(REV.101831 ��T p�1 L4-1 C-s 6 <br /> EH 14.25 <br />