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_ <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. <br /> 45, !t <br /> Job Address — T !/ City � Lot Size PM <br /> Owner's Name <S,4 R y A 1Q/, N I Address '� Phone U <br /> TYPE OF WELL/PUMP: NEW WELL ,� WELL REPLACEMENT ❑ �i`,�DESTRU TION ❑ <br /> PUMP INSTALLATIO�� SYSTEM REPAIR ❑ •��.�OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK ��O f - SEWER L1ATE5L.-.�.. DISPOSAL FLD.} '- � PROP. LINE <br /> FOUNDATION - ,�AGRICUI TORE WELL '­•.OTHER WELL PITS/SUMPS <br /> INTENDED USE TNPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS •/ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavat't' n Dia. of Waif' asinng <br /> Domestic/Private )(Gravel Pack ❑ Tracy Type of Casing T Specifications <br /> ❑ Public ❑ Other ❑ Delta ,Depth of Grout,Se /,$70 / Type of Grou – A/)r <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installe y <br /> Repair Work Done Q,�_Type of Pump H.P. State Work Done <br /> Well Destruction n Well Diameter Sealing Material (top 50') <br /> Depth miller Material (Below 501 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAMIADDITION-0 DESTRUCTION ED (No septic system permitted if public sewer is <br /> [ � available witklin 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> + Character-ofiso I,Cq a depth of 3 feet: Water table depth <br /> SEPTIC WANK ❑ Type/Mfg Capacity No. Compartments <br /> e <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 1A <br /> LEACHING LINE ❑ No. & Length of lines w Total length/size <br /> FILTER BED i ❑ Distance to nearest: Well Foundation Property Line �ajVr� <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS I ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS t ❑ <br /> hereby certify that,l,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, 1 shall not <br /> employ any person iQ/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 applican must c for uired inspe tions. Complete drawin(v�n r verse side..{ <br /> Sign 4L Title:" Co A T /ici T o t< Date: <br /> FOR DEPA TMENT USE ONLY <br /> Application Accepted by Date ,� Area <br /> Pit or Grout Inspection by ' Date &TO Final Inspection by DateR-1Z—&0 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 l Tracy 8355-6385 <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 CKCASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.I i s 5) INFO '�_. •�_ ` ��.11�� W <br /> EH 1428 <br />