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- APPLICATION FOR PERMIT ldllr ��,Q. WYE' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE_STOCKTON, CA <br /> F Telephone (209) 466-6781 <br /> t <br /> PERMIT EXPIRESA YEAR FROM DATE ISSUED t <br /> (Complete in Triplicate) Y <br /> Application is heieby 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 <br /> Owner's Name <br /> r✓ City Lot Size PM <br /> Phone <br /> JJ *" Address <br /> I Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION X SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE —TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> El Industrial ElOpen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑'Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑Irrigation� ' �. k-- Approx. Depth ❑ Eastern Surface Seal Installed by -. <br /> Repair Work Done '-O Type of Pump CL H.P. [� State Work Done_yy x*r-,As V:) �e <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> r 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 r <br /> Number of living units: Number of bedrooms <br /> r <br /> ' Character of soil to a depthof3 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 ❑= Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 /> I 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."Contractors 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 persons subject to workman's compensa- <br /> tion laws of California." ' <br /> The applicant u ca or all re tF-ed,ihspections. Complete drawing on reverse side. <br /> i Signed X ,//�" �'aTitle: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date — %Q ` Area p <br /> Pit or Grout Inspection by Date Final Inspection by Date CJ <br /> Additional Comments: 1 � <br /> ❑ Stk 466-6781 K� Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE, AMOUNT REMITTED CA5H RECEIVED BY DATE PERMWISIO. <br /> INFO <br /> + EN 13-24(REV.I/e 51 �-� } ! 1—�^ �5 •'�SZ3 <br /> EH 14-28 <br />