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M <br /> 4 _ <br /> AWLICATION FOR PERMIT <br /> ( SAN JOAQUIN.LOCAL HEALTH DISTRICT <br /> 1601 E.,HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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. y. <br /> Job Address; � f CitySize PM <br /> t <br /> E Owner's Name 4LAddress �� Phone r` 06 111 <br /> J' Contractor's Name License No. "' 70 Phone <br /> "NEWW <br /> TYPE OF V17ELL/PUIVIPC -'' ELL'❑ WELL REPLACEMENT-Ll"-" 'DESTRUCTION 11 ---T ` <br /> -� �-�PUMP-INSTALIATION,.❑ �� � -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 TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation -# A Dia:of Well Casing <br /> �1 <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f❑r Public ElOther LIDelta Depth of Grout Seal Type of Grout <br /> `440 Irrigation - --Approx. Depth ❑ Eastern Surfpce Seal Installed by L­ — - - <br /> `Repair Work Done Type of Pump _ H.P. Stwe�Work Done <br /> _ W <br /> -,Well Destruction C1 Well Diameter Sealing Material {top 50T <br /> ` Depth Filler Material (Below 501 <br /> ---STYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence� Commercial— Other <br /> Number of living units: Number of bedrooms r <br /> w Character of soil to a depth of 3 feet: Water table depth P <br /> SEPTIC TANK ❑ Type/Mfg r Capacity No. Compartments <br /> 'PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ?.LEACHING LINE ❑ No. & Length of lines Total length/size <br /> w FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size g' Number <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 /> 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."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 applic u call for all redin ctions. plete drawing on r e,side. <br /> Date: 1 <br /> Signed Title: <br /> F R DEPARTMENT USE ONLY .ry <br /> Application Accepted b <br /> Date r Area 92 <br /> Pit or Grout Inspection. y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466.6761 ❑ 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 CASH RECEIVED BY DATE PERMIT'NO. <br /> r INFO ! <br /> + EH 13-24 MEV.10/831 <br /> EH 14-26 _ <br />