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. � y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address - Z�Ek Vrn ' J r City J 7?�4141_ /V Lot Size PM <br /> Owner's Name _�;���/ f1 � /i Address <br /> Contractor r >� _Address.- _ 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 R 4 <br /> I-) Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation `Dia. of Well Casing v <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H"P. State Work Done <br /> I <br /> Well Destruction ❑ Well Diameter Sealing Material flop 501 ! <br /> Depth Filler Material (Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DE=STRUCTION Mo septic system permitted if public sewer is 4 <br /> available within 200 feet.) <br /> Installation will serve: Residence _ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> 9 <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 T <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> SEEPAGE PITS ;'t) ,;Depth Size Number <br /> SUMPS L Distance to nearest: Well Foundation Property Line. � �� <br /> DISPOSAL PONDS ❑ <br /> 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 l} <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, I shall employ persons subject to workman's Compensa- <br /> tion laws of California." i <br /> The applican c I for all require ' spectio . Complete drawing on reverse side. <br /> r <br /> Signed Title: t,51 <br /> / Date: , <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area /d <br /> I <br /> Pit or Grout Inspection by / Date Final Inspection by Date <br /> Additional Comments: 3`t <br /> ❑ Stk 466-6781 ❑ Lodi 369-3d2l ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant Return all copies to: Environmental Health Permit/Services 11301-E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> + EH 14.26(REV.r i H 51 w./r V`Q t�e_�4 <br />