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Air <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. FIAZELTON AVE., STOCKTON, CA <br /> Telephone {2091 466-6781 r <br /> PERMIT EXPIRES 9 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is heaeby 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 /> 2 � <br /> Job Address City - of Size PM <br /> Owner's Name \ Address r ; lee PhoneF <br /> ntfactor Address License No. Phone <br /> TYPE OF WEL / U P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ eca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pac ❑ Tracy Type of Casing Specifications <br /> r-I Public Cl r Cl Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —.-Approx. Depth l l Eastern Surface Seal Installed by <br /> Repair Wo one 13 Type of Pump H.P. State Work Done_ <br /> W estruction ❑ Well Diameter Sealing Material Stop 50'1 <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I i DESTRUCTIONVNo 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 <br /> Character of soil to a depth of 3 feet: Water table depth I' <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to clearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I <br /> I hereby certify that t 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 applicant st ca fo I requirefhspections. Complete drawing on reverse side. <br /> Signed X ! Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ' OIC Date f <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-362 Manteca 823-7104 ❑ Tracy 835-638 <br /> Applicant - Return all copies tib: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24(REV.vnsi <br /> EH 14-28 <br /> A <br />