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APPLICATION FOR PERMIT <br /> . b <br /> s SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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/pump p and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address v City of Size . PM <br /> �.. <br /> r <br /> Owner's Name Address Phone <br /> Contractor. Ct <br /> Q2��dOress ? License No. Phone r <br /> { TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT DESTRUCTION ❑ <br /> i y i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> ! DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> 1 FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS °3 O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r` <br /> 4 <br /> t ❑ Industrial E ❑ Open Bottom 0 Manteca •• . Dia. of Well Excavation Dia. of Well Casing <br /> s <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ` Specifications <br /> Ll Public ❑ Other ❑ Delta Depth of Grout Sea! k Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑'Eastern Surface Seal Installed by. <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 501 y1"y <br /> Depth Filler Material 100lmy 507" <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION El septic system permitted if public sewer is <br /> } I ,,. ''" t available within 200 feet.) <br /> Installation will serve: Residence Commercial <br /> Number of living units: 1Number of bedroa s <br /> Character of soil to a depth of 3 feet: Water table,depth-,- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Comparirnents: <br /> i PKG. TREATMENT PLT. ❑ Method of Disposal�i <br /> ..•.. <br /> Distance to nearest: Well Foundation ,.Property Line = i <br /> F LEACHING LINE ❑ No.�& Length of lines Total length/size <br /> . FILTER BED ❑ Distance to nearest: well —R'Foundation *. .Property •Line " <br /> SEEPAGE PITS Q Depth Size x IR� dumb <br /> ter 't <br /> SUMPS Distance to nearest:'- Wei l• dation _I Property Line ^Ja <br /> DISPOSAL PONDS ❑ 4 " <br /> I hereby certify that I have_pmparerl_this application and-that-,the work will be done in accordance with•San Joaquin county ordinances, state laws, and <br /> I rules and regulationsof the San Joaquin Local Health District. ` — -';% I <br /> Home owner or licensed ageni'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 x <br /> certifies the fallowing: "I certify that in the peffoi•mance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." 4 <br /> 1` �. 4 t' <br /> The applicant st c all re I..red•in tion . Complete,dWgon. se'si8e.rSigned j - Date: <br /> FORT USE ONLY 1 l <br /> Application Accepted by ` 4 Date V Are <br /> Pit or Grout Inspection by "5��� Date ` 'Fjnal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ Manteca. 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 <br /> FEE AMOUNT'DUE AMOUNT REMITTED CK 40 RECEIVED BY' DATE PERMIT NO. <br /> INFO CASH <br /> i. a EH 13,24MEV.t�a5f -. - `'y �- - - 95— "1 <br /> i, . <br /> 41� EH 14-28 <br />