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APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Addressr <br /> tV- Lot Size PM <br /> r <br /> Owner's Name - Address <br /> Phone — <br /> Contractodress ` icense NorJt/+�- —'7 <br /> Q7 Phan <br /> TYPE OF WELL/PUMP: . NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION � F <br /> PUMP INSTALLATION 171SYSTEM REPAIR ❑ � // .L <br /> OTHER ❑ !r <br /> DISTANCE TO NEAREST: SEPTIC TANK�� SEWER LINES>Z DISPOSAL FLD , 6r--'�/'��_ PROP. LINE yT <br /> FOUNDATION> � AGRICULTURE WELL )/� OTHER WELL PITS/SUMPS`f o <br /> INTENDED USE TYPE OF WELLPROBLEM AREA CONSTRUCTION SPECIFICATION -- <br /> -- <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> M PublicSpecifications <br /> T175W/ MZT'--� ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation s <br /> 9 t vv_Approx, Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Dane , <br /> Well Destruction ❑ Wel! Diameter Sealing Material Itop 50'I <br /> Depth Filler Material (Below 5011. <br /> ------------------ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION f I DESTRUCTION f I (No septic system permitted if public sewer is <br /> Installation will serve: Residence--�_ Commercial, Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: <br /> SEPTIC TANK O Water table depth Type/Mfg Ca acit , <br /> p Y No. Compartments <br /> PKG. TREATMENT PLT. LIj <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED D Distance to nearest: Wel! Foundation Property Line <br /> 4' <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> Property Line <br />--.—dESPOSAt PONDS--­:�C-7--�.e:.����. ���_::�-- -..—.. <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 <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 s <br /> certifies the following:"I c rtify 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 alifor <br /> Thea lie m all r all r ed ins ns. Complete drawingon r rse side ' <br /> Signed <br /> Titl <br /> Date: <br /> OR DEPARTMENT USE ONLY j <br /> Application Accepted by Date W: fJ <br /> U Area <br /> Pit or Grou Inspection by VY-\ <br /> Date Z f Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> a / <br /> FEE AMOUNT DUE AMOUNT REMITTEp CK <br /> INFO CASH '""RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-24 IREV,i i n 51 'u ' <br /> EH 14-26 `-'r <br />