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APPLICATION FOR PERMIT �» <br /> y"f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> l 1601 E. HAZELTON SAVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED r , <br /> (Complete in Triplicate) <br /> r'Y application is <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 <br /> made in compliance with S n Joa uin Cpuyity Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> a - , 7 <br /> Local Health District. `` 4 <br /> l "''' City <br /> Job Address Lot Size .0� PM <br /> ` FQl _ <br /> Address Phone <br /> Owner's Name � - - <br /> y5�� , .- License No���Phone <br /> Contractorpv Address_ <br /> 4 TYPE OF WELL/PUMP: NEW WELL Yom' WELL REPLACEMENT ❑ DESTRUCTION 171 <br /> PUMP INSTALLATION Lam` <br /> SYSTEM REPAIR ❑m OTHER :1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. �s0 PROP. LAVE <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing S <br /> k ❑ Industrial pen Bottom Manteca Dia. of Well Excavation Specifications L ' <br /> i omestic/Private ❑ Gravel Pack ❑ Tracy • Type of Casing <br /> ❑ Delta Depth of Grout Seal _�6 Type of ou <br /> El.Public ❑ Other - � <br /> ❑ Irrigation �PPCox. Depth ❑ E stern Surface Seal Installed by <br /> H P State Work Done <br /> Repair Work Done ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> R <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ R_EPAIRIADDITION ❑ DESTRUCTION ❑ available blelwi hin 204 feet fed if public sewer is <br /> rn <br /> Installation will serve: Residence— Commercial_ Other <br /> j Number of living units: Number of bedrooms Water table depth <br /> 1 Character of soil to a depth of 3 feet: <br /> Capacity' l No. Compartments <br /> SEPTIC TANK E] Type/Mfg � — t%k„, Method of Disposal <br /> PKG. TREATMENT PLT. ❑ y� Property Line <br /> Distance to nearest: Well Foundation-, <br /> ir ❑ No. & Length of lines '} �` k Total length/size <br /> LEACHING LINE �' ~� �. <br /> FILTER BED ❑ Distance to nearest: Well Foundation'' Property Line <br /> Number <br /> SEEPAGE PITS ❑ Depth Size _ <br /> f Property Line +� <br /> r SUMPS El Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ ,� ,1 <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 Contractor's <br /> o tract ws hiri g perry-6t issued,g�i _nshall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor s hiring or sub cortrac#in Si nature <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 workma'n's compensa- <br /> tion laws of California." <br /> The applicant mus all for all required inspections. Complete drawing on reverse side. p <br /> Title:' Date: �= °� 1. <br /> SignedOr <br /> +` <br /> OR DEPARTMENT USE ONLY _ <br /> Application Accepted by <br /> � <br /> Date • Area <br /> Pit or®rouInspection by <br /> ate Final Inspection by <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 El Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all o ies to: Environmental Health Permit/ServicesE. <br /> Ave., P.O. Box 2009,Stk., CA 95201 <br /> k <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMI7`ND. <br /> y INFOt - 1575 <br /> +EH13-241REV.1/a5} C3,<. <br /> EH 14-26 <br />