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z APPLICATION FOR PERMIT <br /> yy ,gym-e+ - <br /> n SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 E. HAZELTON AVE., STOCKTON, CA a i <br /> Telephone (209) 466-6781 <br /> I <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 Regulaiions of the San Joaquin <br /> Local Health District- <br />, <br /> Job Address- City PM <br /> y ? <br />" <br /> Owner's fla�MJF! = - r Address _ _ _ Phone <br /> Contractor- 1 cense No. Phone <br /> ZL <br /> .g <br /> ,.TYPE OF WELL/PUMP: NEW WELL ❑i WELL REPLACEMENT El DESTRUCTION ❑ <br /> `- PUMP INSTALLATION ❑ SYSTEM REPAIR 71 % OTHER ❑ P <br /> DISTANCE TO NEAREST: SEPTIC TANK _ SEWER LINES bISPOSAL FLD. PROP. LINE k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS + <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom -0-Manteca Dia- of Well Excavation Dia. of Well Casing. <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public ❑ Other ❑ Delta Depth of Grout Seal .^Type o_f,Grout <br /> I I Irrigation _:,, pprox. Depth... I 1 Eastern Surface Seal Installed by " • _ _ — J <br /> -Repair Work Done' ❑ Type of Pump "i' H.P. -I tate Work Done _ f <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50;) l <br /> Depth Filler Material IBelo ) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR IADDITION T DESTRU ION t-I�(No septic-system-permitted,if-public sewer-is:- <br /> t } $ available within 200 feet.) <br /> Installation will serve: Residence •f. Commercial_ Other r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water tahle'deAth A , <br /> SEPTIC TANK LIT } n <br /> ype/Mfg Capacity No.'Compartments - <br /> PKG. TREATMENT PLT. 0 jet <br /> Mhod of Disposal <br /> h r <br /> p Distance to nearest: Well _ ndation._.-!_2- Property Line <br /> LEACHING LINE ❑ No. & Length of hos Total-length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well tioh• Property Line./6;, <br /> SEEPAGE PITS I I Y Depth`• Size lumber <br /> SUMPS ❑ Distance to nearest: ~Well ' undation Property Line <br /> DISPOSAL PONDS . a C7• <br /> �x <br /> I hereby certify that i Nave 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 /> r employ any person in such manner as-to•becomJ'subiect-to wprkman'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." I p <br /> The applicant st r a require s ctions. Co I drawing,on rs side. y , ��'• - <br /> Signed rTitle:' Date: <br /> i •_ FOREPARTMENT USE"ONLY r ' <br /> Application Accepted by Date a Area <br /> Pit ar Grout tnspectian by Date .Final Inspection by Date r <br /> Additional Comments: <br /> ❑ 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 INFO «A-MyOU1NT DUE AMOUNT REMITTED CK 9 CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(I{mrirs5) / V ' oy (�� 12?`153EH 14-26 - ! v �.,! r, l <br /> • F <br />