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APPLICATION FOR PERMIT ' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> cribed. This <br /> rk <br /> n des <br /> Application is cohereby mpliance with e to the San <br /> JoaquinnJo iCounty Ordinance cation is <br /> aquin lNo.549 for sewage or ealth District for a permit <br /> 1862 for construct and/or <br /> and the Rules and 1Regulationss of he San r Joaquin <br /> made P <br /> Local Health District, <br /> City Lot Size 6 ? PM <br /> Job Address <br /> `�- Phone ` <br /> ss <br /> Owner's Na <br /> Contractor Address <br /> License N one <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> TYPE OF WELL/PUMP: NEW WELL ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK = SEWER LINES -- <br /> DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> El Industrial l7 Operi Bottom ❑ Manteca Dia, of Well Excavation, 3 <br /> Type of Casing' -' �'.=' �. '"ti` Specifications <br /> ❑ Domestic/Private' '❑ Grave! Pack ❑ Tracy - r �. YP r _ Type of Grout—.- <br /> 1-1 <br /> rout <br /> C'1 Public ""•""'""Depth of'Grout Seal <br /> Cl Other (l'De1ta-�-�^ 1 <br /> I I irrigation —_-Approx. Depth' I I Eastern­_ Surface Seai{Installed by <br /> H P State Work Done# <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (tap 50'1 <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION iJ DESTRUCTION I I available septic system <br /> permitted if public sewer is <br /> lnstaNatian will serve: Residence"� ,Commercial— Other <br /> Number of living units: _/_ Number of b ro Water table depth r <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity No. Compartments <br /> y : Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> 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 11 Depth ' Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> ify that in the performance of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signature certifies the following: "I cert <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of-ihe-work-for-which.this per sit is.issued-,I shall employ persons subject to workman's compensa- <br /> tion laws of California." � <br /> The applicant must 11 for all required ' pec' o plate wing on rev se slde. %f� <br /> f Signed X <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> Application Accepted by <br /> -� <br /> Date,' --2- <br /> Date Final Irispectio'n byJ <br /> Pit or Grout Inspection by _ 1 <br /> i Additional Comments: <br /> ❑ Stk 466-6781 C1L di 369-3621 In 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 /> FEEAMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> I INFO <br /> S <br /> LS + 1:H 13-24 IAEV.I/H 51 �-1 1-3 x`7-1� <br /> EH 14-28 <br />