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.� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone(209) 486-6781 <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 yj th San Joaquin County Ordinance No.549 fon sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health Distr' <br /> Job Address 1� +"�, r'7`� �.�(�� T.l� City Lot Size PM <br /> Owner's Name /'/il�i�,/�/�t�ST' — Address �1w7-S4Ak—,' P Phone' � <br /> Contractor S Address -;ZIPV'�P w License No. Phone 9 / <br /> TYPE OF WELL/PUMP: NEW WELL, WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK MOL SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL - OTHER WELL - PITS/SUMPS It <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATION Ar <br /> ❑Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing // <br /> 5 <br /> Domestic/Private PGravel Pack 111 Tracy Type of Casing Specifications <br /> © Public ❑0OOy,tp�er ❑ Delta Depth of Grout Seal Type of Grout �✓1 <br /> ❑ Irrigation oCicvApprox. Depth E] Eastern <br /> Seal lnstaNetf by <br /> Repair Work Done ❑ Type of Pump � H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material(top 501 <br /> Depth Filler Material(Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION❑ DESTRUCTION ❑ (No septic system permitted if public se~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 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT.❑ Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> LEACHING LINE O No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> I hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county state;lows,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,tW-' <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contras ' <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�- <br /> tion laws of California." <br /> The applicantt all r tions. Complete drawing on re rse de. <br /> Signed Title: i�C� G!✓� Date: z�hZ <br /> FOR DEPARTMENT USE ONLY <br /> Application,Accepted by .y Date ��_ Area <br /> Pit inspection by Date ( v Final tby Data <br /> n <br /> Additional Comments <br /> Stk 466.6781 ❑Lodi 369-3621 ❑ Manteca `823 7104 ❑Tracy <br /> Applicant-Return all copies to:Environmental Health Permit/Services 1601 E. Hazelton Ave.,P.O. Box 2009,Stk., CA 96201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT`NO. <br /> +EH 1324(REV. es) T� <br /> EH 1428 V / / <br />