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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES T 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health y <br /> District. 4 5&aw ar <br /> 1 cam,r <br /> 12 <br /> ,lob Address - City � Lot Size PM <br /> Owner's Na�&= <br /> t aLJ� ddress 7'¢ - Phone —� <br /> A <br /> Contractor Addtess Crr��r t_icensefNo !. _ Phone -" C� <br /> r•1� <br /> oei <br /> TYPE OF WELL/PUMP: NFN WELL ❑ WELL REPLACEMENT ❑ 'DESTRUCTION)io 3 <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 6 <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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f`1 Public y 17 Other Q ❑ Delta Depth of Grout Seal Type of Grout <br /> I i Irrigation" - Approx,:,Dept h- -1-I~Eastern•= Surface-Seal-Installed_by— <br /> Repair Work Done ❑ Type of Pump_ H.P. State Work Done_ <br /> Well Destruction ❑ Well Diamete_' ` Sealing Material (top 50') <br /> Depth Filler Material {Below 50'1 s __ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION i I DESTRUCTION f I (Nose <br /> ptic system permitted it public sewer is I <br /> available within 200 feet.) <br /> Installation will serve:. Residence Commercial_ Other <br /> Number of living units: Number of bedrooms_ f <br /> Character of soil to a depth of 3 feet:" Water table depth <br /> SEPTIC TANK ❑ Type/Mfg:) Capacity— t';No. Coartments <br /> PKG. TREATMENT PLT. C1 Method of Disposal <br /> i <br /> Distance to nearest: Well Foundation Property.Line � " <br /> LEACHING LINE ❑ No. & Length of lines 4 Total length/size <br /> FILTER BED ❑ Distance to;dearest: Well Foundation 4 Property Line ' <br /> 3 � 1 <br /> SEEPAGE PITS 1 1" Depth Size N�,,i Number <br /> SUMPS L.I Distance tornearest: Well Foundation Property Line ; <br /> DISPOSAL PONDS ❑ `• <br /> I hereby certify that I have prepared this application and that the work will be'done inaccordancewith San Joaquin county ordinances, state laws, and C� ' <br /> rules and regulations of the San Joaquin Local Health Diltrict. <br /> Home owner or licensed agent's si nature certifies the following: <br /> 9 g g: "1 certify that in the'jierformance 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,C`alifornia.",Conttactor'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 persohs subject to workman's compensa- <br /> tion laws of California." <br /> The applicant I require '_ 1 , Complete drawing an reverse,side. <br /> i <br /> Signed X to: I pate: <br /> t <br /> FOR D?EPA <br /> RTMENT USE ONLY <br /> Application Accepted by <br /> Date ! CJ i/ Area <br /> s <br /> Pit or Grout Inspection by s Datd4 ��' t I <br /> ���F nal Inspection by - � �^ Date47 <br /> Additional Comments: <br /> LJ Stk 466-6781 ❑ Lodi 369=3621"` ❑ Manteca . 823-7104 U Tracy 835-6385 i <br /> Applicant - Return all copies to: Environmental Health Permit/Sfarvices 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE " AMOUNT REMIITTED y CASH RECEIVED BY ` DATE PERMIT"NO. <br /> +-EH 13'24 EH 14-2e'REV.i i H SS S. V�--% 0,� <br />