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.1 <br /> w <br /> APPLICATION FOR PERMIT <br /> SANJOAQUIN 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 /> Job Address / 'City 'S��of Size PM <br /> Owner's Namef"' Address Phone �lr���� <br /> Contractor wahr k PVM01k AddreEARL <br /> License No.10Y5,4f Phone 8,f <br /> TYPE OF WELL UM . NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR JN 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 Dia. of Well Casing <br /> domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> `[��-/I Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> �Irrigation --Approx. Depth i I Eastern Surface Seal Installed by ji ��IReepair Work Done ❑ Type of Pump JFT H.P. P State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50')Depth Filler Material (Below 50')TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTION I l 1No septic system permitted if public s <br /> 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 /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line ; <br /> SEEPAGE PITS I 1 Depth Size _ 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. i <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 mannet 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 mll or all required inspections. Complete drawing on reverse side. <br /> Signed X_ 10 Title: Date: <br /> FOR DEPARTMENT USE ONLY f�j <br /> � Application Accepted by Date �� / Area G— <br /> Pit or Grout Inspection bate Final Inspection by /y t - `41 1 Date= r" 7 <br /> Additional'Comments: ; <br /> ❑ Sik 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104., ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 11601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> kFEEO AMOUNT DUE AMOUNT REMITTED C 17A9H RECEIVED BY DATE PERMIT NO. <br /> EH 3-24 <br /> EH 14-26 TREY,t i k Sl .1 <br /> V VV / t7(Q <br />