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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 Address City r�_ Lot size 6 /0 a PM <br /> Owner's Name WLS Address Phone -yo <br /> Contractor Address1j l 0AI/�License No. �'\l Phont �� <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 pQ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS � <br /> ❑ Industrial E,Open Bottom t ❑ Manteca � Dia.<of'Wall Excavation r<, 2S Oia:of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack € ❑ Tracy Type of Casing Specifications ,/ <br /> 4. <br /> .i <br /> 11Public Other I ❑ Delta Depth of Grout Seal Type of Grout �p <br /> ❑ Irrigation ___Approxf.Depth ❑ Eastern-w,....__.,-Surface Seal Installed by <br /> Repair Work Done ED Type of Purfip H.P. F fState Work Done <br /> Well Destruction C1Well Diameter Sealing Material (top 50'1 r" <br /> Depthr Materi�I BeloVv 5"0') <br /> TYPE OF SEPTIC WORK: `NEW INSTALLATION ❑ REPAIR ADDITIOT DE rTRUCTION ❑ (No gepfiClsysieft permitted if public sewer is <br /> available within~ feet.) <br /> Installation will serve: Residence_ CommercFal _Other- .l <br /> �. <br /> Number of living units: � 'Number of bedrooms <br /> Character of soil to a depth of 3 feet: 1 --- atertable depth" � � <br /> y, P <br /> SEPTIC TANK ❑ Type/� ig _ l"" Capaci No. Compartments <br /> PKG. TREATMENT PLT. ❑ s l i1Z j r Method ofDisposal <br /> Distance to nearest: W1 II Foundation koperty Line <br /> LEACHING LINE I No. & ength of lines _� Total le gth/size <br /> FILTER BED ❑ Dista to nearest: Welt FoundatiojIM2!�_,/Pr.perty Lind1 - <br /> SLEPAGE PITS i Depth —0,1- Size Number. i <br /> SUMPS ❑ 1 Distance to nQarest: Well Foundation Pro Line <br /> DISPOSAL PONDS ❑ 1 <br /> r <br /> I hereby certify that I have prepared this apl$ication And t6t`the m#k`will be done in`accor arice with San Joaquin coun4-brdinancee:state laws, and <br /> rules and regulations of the San Joaquin Loral Health District. - r.j i <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fdr which.this permit is issued, I shall not <br /> employ any person in such manner as to"-becalne subject xo workman's compensation laws of California."Contractgr!s"'ftiring 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 o rnia." <br /> The applic nt must all fo ll req ed insp tions. Complete drawing on reverse side. <br /> Signed Title: Date: " <br /> FORWDEPARTMENTEONLYApplication Accepted by �[✓ Date AreaPit or Grout Inspection by DateInspection by Date z <br /> A ditional Comments: t��. <br /> 466-6781 ❑ Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BYDATE PERMIT NO. <br /> + EH 13-241REV.t/n5l �ti}• OaQs� CV <br /> EH 1M26 Y <br />