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%t <br /> 3Vr _tel <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 the San Joaquin <br /> Local Health District. <br /> Job Address 3r �r City Lot Size PM <br /> Owner's Name v Address Phone <br /> } �7 <br /> Contractor 6 _Address f� License No.LD �Phone C. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINT= <br /> 77�DATION AGRICULTURE-WELL OTHER WELL Pi MPS <br /> INTENDED USE TYPE OF WELL BLEM AREA CONSYRUC ATIONS <br /> Cl Industrial ❑ Open Bottom ❑Mantec .— ia. of Well Excavation f-Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Typ Casing Specifications { <br /> 1-1 Public er C1 Delta • Depth of Grou I Type of Grout _. <br /> I I Irrigation _.:Approx. Depth i I Eastern _ Surface Seal Installed <br /> Repair Work Done ❑ Type of Pump H.P. State Wo e _ I <br /> Ov <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') - N <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION 1 I DESTRUCTION INo septic systemfpermitted if public sewer is <br /> vaitable within 200 feet.) {1 F <br /> Installation will serve: Residence— Commercial_ ,Other I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK © Type/Mfg Capacity `"No. Compartments <br /> PKG. TREATMENT PLT. ❑ k, / Method of Disposal <br /> Distahce to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. A Length of lines Total length/size - <br /> 1 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> s <br /> SEEPAGE PITS l I Depth Size _ Numbei "�--- - <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 lowin :"I certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion lawso C ' r a." <br /> The applic t 11 for all requited inspections. Complete drawing own reverse side. <br /> Signed X Title: hla.(� Date: <br /> FOR DEPARTMENT USE ONLY _ <br /> Application Accepted by Date -" 1) AArea <br /> nt �1 0- <br /> I Pit or Grout Inspection Date Final Inspection by J. Date <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 AMOUNT DUE AMOUNT REMITTED U RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> +.EH 13-241REV.tins) r' %rajtag gfi <br />