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APPLICATION FOR PERMIT <br /> i <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 qthe GSan Joaquin <br /> Local Health District. <br /> izet] A-aL/�M r <br /> Job Address <br /> Owner's NameA4-�� 3 3ko <br /> Contractor dry"s �a C License Na oneZ�Ce7 <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT [71- - DESTRUCTION Q <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER O <br /> DISTANCL TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP.<LINF <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS p <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavatio Dia. of Well'C9a 1 g ^ <br /> ❑ Domestic/Private 11 Gravel Pack El Tracy Type of Casing Specifications— <br /> F] Public 1"1 Other 71 Delta Depth of Grout Seal C Type f rout <br /> I I irrigation —Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump � H,P. — - State Work Done <br /> Well Destruction F- Well Diameter Sealing Material (top 501 <br /> Depth Filler Material 1 Below,50') <br /> TYPE OF SEPTIC WORK: - NEW INSTALLATION 1.1 -REPAIR/ADDITION I I DESTRUCTION I I.(No 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 m <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments r <br /> PKG. TREATMENT PLT. ❑ Method of Disposal, <br /> r <br /> Distance to nearest: 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 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. <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,t shall employ persons subject to workman's compensa- <br /> tion laws of California." - x <br /> Theapplicant must call for all required,iiispections Complete drawing on reverse side. T _ T <br /> g <br /> Si ned X <br /> c�Q'�•�. 0�1Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Date <br /> Pit or Grout inspection by Date Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 ,Lodi 369-3621 D Manteca 823-7104 © Tracy 835-6386 <br /> Applicant - Return all e6piels to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> l IFEE NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> ♦.EH 13.21(REV.1/e 5) S77- <br /> EH <br /> 7 /ZEH 1A-28 r <br />