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' I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 lhe ules a nd Regulations of the San Joaquin <br /> Local Health District. ��o[ o;;;, <br /> Job Address Ma & I _ City Lot Size PM C <br /> Owner's Name4 Address f -i+ *_ __hone S- ` <br /> Contractor's Name w License No. Phone <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. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications W <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation—"—­—t_Approx'Depth—❑ Eastern"'"`"'Surface Seal Installed 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 i Bel9w 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> F, I d available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> I Number of living units: * W Number of bedrooms ?(b <br /> Character of soil to a deptf%f 3 feet: 904 Vir-I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments ° <br /> PKG. TREATMENT PLT. ❑ i Method of Disposal } <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE CCr'No. & Length of lines Total length/size ; <br /> FILTER BED ❑yw Distance to nearest: Well Foundation Property Line <br /> fkk SEEPAGE PITS Depth Size Number <br /> kSUMPS E3Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ai err# <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. ' I <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." Contractors 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 sh6.11 employ persons subject'to workman's compensa- <br /> tion laws of California.' M <br /> The applicant m st Fall for all required;i spe ti Complete drawing on re rse side. ^a ' <br /> Signed s TitLe:- #" Date: `OOOp <br /> FOR DEPARTMENT USE O � Xi I , J <br /> [�.� �uk/.G�ti� eJDate - " '," t Area <br /> Application Accepted by (� <br /> Pit or Grout Inspection by {' _-- '-t'I rb'�`Q Final Ir�pction by�'tiJL�*.�w�de • ' � a7ateQZ <br /> Additional Comments: <br /> ❑ Stk 466-67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy,,835-6365 .. ' ., <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 CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ' J_2 <br /> +EH I3-24(REV.10183! eu �PL !V� �f� '6_ - � <br /> EH 1426 S o <br />