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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 <br /> Local Health District. /pump and the Rules and Regulations of the San Joaquin <br /> yna vi <br /> Job Address �i2fO �, a v ,• 1 y zM �. <br /> City.- Lot Size PM j <br /> Owner's Name / Address r, C�:a r 1 <br /> Phone �Cl <br /> Contractor Address <br /> TYPE OF WELL/PUMP: License No. Phone <br /> N WELL ❑ WELL R LACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Q <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ y <br /> SEWER LINES' DISPOSA9FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER 1 L <br /> ELL <br /> INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> t—rk= <br /> Q Industrial ❑ Open Bottom ❑ Manteca <br /> Dia.-of Well Excavation`'t``! 4►. <br /> ❑ Domestic/Private Q Gravel Pack Dia. of Well Casing <br /> ❑ Tracy T <br /> Q Public :yPp.rof:C-asing Specifications <br /> ❑ Other Q-Delta Depth of Grout Seal <br /> ❑ Irrigation Approx. Depth ❑ Eas_tern. Type of Grout <br /> Repair Work Done ❑ Type of PumpSurface_Seal.�nstalled=by. <br /> H.P. State,Work Done <br /> Well Destruction ED Well Diameter r I <br /> Sealing Material (top 50'1 i <br /> Depth Filler Material (Below 50') i <br /> TYPE OF SEPTIC WORK: NEWr.INSTALLATION ❑ REPAIR/AODITION Q DESTRUCTION I <br /> • (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 bedroom <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg No. C <br /> Capacity - d <br /> PKG. TREATMENT PLT. ❑ Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> �1 Property Line <br /> LEACHING LINE ❑ No& Length of fines <br /> FILTER BEDTotal length/size j <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line , <br /> SEEPAGE PITS ) <br /> Q Depth �Size F <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Q Property Line - 6 <br /> hereby certify the I have re - - _ - �-..j-- <br /> p pared this application and that the work`wiii be done in accordance with San Joaquin county ordinances, state Iaws,Land <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 shelnot <br /> employ any person 1n 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 cern that in the performance of the work for which this <br /> I permit is issued, I shall employ <br /> M� ort laws of California." p y persons subject to workman's compensa- <br /> 4The applicant mus for all required i ions. Complete drawing on reverse side. <br /> Signed r7 <br /> Title: Z 1/1IleDate: <br /> FOR DEPARTMENT USE ONLY <br /> �OAPPlication Accepted by 0 /DateArea /tor Grout lns n by DateFinal Inspection by Date <br /> Additional Common : 6 Z) ..�s � <br /> ❑ Stk 466-6781 -0 Lodi .369- 1 ❑ Manteca 823-7104 ❑.Tracy 635 6385 <br /> Applicant- Return ll copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 ' <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED f3Y DATE H;ERMEH 13-24(REV.1/B5)EH 1428 i �� 074 <br />