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M <br /> t <br /> APPLICATION FOR PERMIT <br /> . SAN JOAQUIN,106AL HEALTH DISTRICT <br /> /} 1601 E. HAZEL T ON AVE., STOCKTON, CA I <br /> V Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1.YEAR FROM .DATE ISSUED y <br /> Y ' <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 ., tri.. City �Y Lot Size .,, PM <br /> Owner's Name Address __...��? Y�C6 tri- Phone <br /> (142 Contractor's Name! . License No. V 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 - "I DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE r TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 4❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private C1 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public . <br /> Other ❑ Delta; Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth- � —Eastern` N Su ace I Installed by <br /> Repair Work Done Type of Pump ( H.P: / Fr State.Work Done* e e <br /> Well Destruction ❑ Well Diameter '-� Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <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 ` <br /> fNumber of living units: Number of bedrooms tea` <br /> Character of soil to a depth of 3 feet: %Nater 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 /> f <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" <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 following:"I certify that in the performance of the work for which this permit isissued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli t call for all requi inspecti S. Comp) a drawing on r e side. *-� <br /> Signed lZ Title: Date: 4P <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area " <br /> I <br /> ion by Date <br /> Pit or Grout Inspection by Date Final InspectZ� <br /> Additional Comments: " <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> ` FEE AMOUNT DUE' AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> +£H 13.24(REV.10183) ` <br /> ��53 <br /> EH 1426 _ <br /> f <br />