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g APPLICATION FOR PERMIT C i <br /> SAN JOAQUIN LOCAL HEALTH_DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA S <br /> Telephone (209) 466-6781 4 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> N� <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 3 <br /> l <br /> Local Health District. .; <br /> Job Address <br /> QJ © r City A"TLot Size PM <br /> \\11 r <br /> Owner's Name <br /> Address —� f�� Phone <br /> Contracto <br /> d d r e s sWe� n e n s e No Phone i <br /> TYPE OF WELL/PUM NEW WELL;'❑ WELL REPLACEMENT ❑ U DESTRUCTION ❑ l <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domesticl Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications d <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal -Type of Grout <br /> I i Irrigation --Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P.�_ State Work Done— <br /> Well Destruction [IWell Diameter " Sealing Materiah{top 50'1 <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i•l DESTRUCTION (No septic system permitted if public sewer is lQ <br /> available within 200 feet.l <br /> Installation will serve: Residence— Commercial_ Other 4 <br /> Number of living units: Number of bedrooms <br /> Character'-of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ l Method of Disposal <br /> Distance to nearest: Well Foundation Property Lute <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size n <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance.to nearest: Well Foundation --Property Line <br /> DISPOSAL PONDS ❑ O <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 /> to an person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ y p n subject to workman's compensa- <br /> tion <br /> the following:"I'certify that in the performance of the work for which this permit is issued, I shall employ Ners� s s t ► <br /> tion laws of Cali rnia." <br /> r <br /> The applica t c f r all requir ins c ons. Complete drawingon erse sidde.. <br /> Signed Tile: Date: <br /> FO TMENT USE ONLY <br /> �F � - 1 <br /> Application Accepted by nn Date �- Area <br /> lPit or Grout Inspection by ate Final Inspection by Date <br /> Additional Comments: —S L(/ �71;17ri <br /> ❑ Stk 466-6781 ❑ LodP 369-3621 ❑ Manteca 823-7104 ❑ Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED 3Fi RE VED BY DATE PERMIT'No. <br /> INFO /` CCJJ <br /> r.EH 1 3-24(rtEv.11K5l � �. <br /> EH t4-28 <br />