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t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> -e�_n [� ego_j ✓ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 1� (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 _T f �GrJ City vt Size PM <br /> Owner's NamelL a GQY[C e.Address _ �t� �� Phone <br /> Contractor Address. i/.�.ro c 4 v�p License No. a Phone g92 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L7 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _._ApprOx, Dept <br /> Repair Work Done LK Type of Pump 5 H.P,h� ]l,Eastern Surf a Seal Installed by <br /> ! <br /> li.� State Work one <br /> Well Destruction ❑ Well Diameter _ Sealing Material (top 501 17 <br /> Depth Filler Material (Below 501 �} <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION (1 REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is `- <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms , <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 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L� 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: '9 certify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's ompensa- <br /> tion laws of California." <br /> The applicant m all for all required ' cti Co plate drawing on r arse side. <br /> Signed ' Title: Date: <br /> FOR IDEPARTMENT USE ONLY <br /> Application Accepted by Date [ ! Area <br /> Pit or Grout Inspection by Date Final Inspection by Date •?--Y7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> 0 RECEIVED By DATE PERMIT'NO. <br /> + EH 14-26 IREV,t i n sl ���.1! yS—t <br />