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F <br /> APPLICATION FOR PERMIT <br /> 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 he,eby 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 /> D� Zy be <br /> City"Lot Size PM <br /> Job Address <br /> Address 33—A j Phone <br /> Owner's Name <br /> f Address License No. Phone_ <br /> Contractor <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT 11 DESTRUCTION F-1 <br /> PUMP INSTALLATION Q SYSTEM REPAIR ElOTHER 171 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Dia. of Wel! Casing <br /> ❑ Industrial LlOpen Bottom l-] Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack 1-1Tracyyp Type of Grout <br /> n Public f=1 Other Cl Delta Depth of Grout Seal YP <br /> i I Irrigation —..Approx. Depth l I Eastern Surface Seal installed by - <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> k Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> f Depth Filler Material IBelow 501 <br />+l TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION t 3 DESTRUCTION i Ivo septic sys <br /> in m rented if public sewer is <br /> IInstallation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of sail 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 ❑ 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 lowr : "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 /> ti2appli <br /> Cal'forn a." <br /> Tnt must or all uire s c ' Complete drawing on `�ide.STitle: Date:F,OR DEPARTMENT USE ONLY <br /> AAccepted by <br /> Date Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: 0 M `-S <br /> ❑ Stk 466-6781 ❑ Lo4i 369-3621 ❑ Mantega 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 /> I FEEAMOUNT DUE AMOUNT REMITTED CASH �RfEC�EIVED BY DATE PERMIT'NO. <br /> ♦ EW 19-24(REV.t/n 5f INFO 4" 100 1�� �} O� p!' ria 1241 1-7 i�-q; � - <br /> VV <br /> £H 14-285 L�JC V <br /> l <br />