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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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 Sart 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 J CityTIAICZ,41y, Lot Size r�C✓ .92C'_t� PM <br /> Owner's Name Z&, _ Address Phone i <br /> Contractor's Name ' Wena Nd' Phone '7 <br /> TYPE OF WELL/PUMP: NEW WELL'❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL-LATIO5><� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES R `' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing , ) <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Dep Eastern Surface Seal Installed by (n <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done /e7� DO <br /> Well Destruction ❑ Well Diameter k Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial= Other y <br /> Number of living units: Number of bedrooms V <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 j <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation ` Property Line <br /> SEEPAGE PITS ❑ Depth Size Number I <br /> SUMPS ❑ Distance to nearest: Well Foundation ' Property Line <br /> DISPOSAL PONDS ❑ I <br /> I hereby certify that I have prepared this application and that the work will"be done imaccordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I 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."Contractor's hiring or sub-contracting signature f <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." <br /> The applicant rpust call for all uire 'ns cti s• Co lete drawing on rev rse side. - <br /> Signed Title: Date: Q 14t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by V Date /d /z ' Area 7 <br /> Pit or Grout Inspection by Date Final Inspectionby 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 2000, Stk., CA 95201 <br /> CK- <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH1324(REV.10183) }} '�1 <br /> EH 1416 - --s• O 0 <br />