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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s <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 I <br /> Local Health District. <br /> - ✓© r <br /> Job Address CitySTI`V <br /> Lot Size PM <br /> Owner's Name P14Y C-f Address Phone ` <br /> Contractor Address .J license No 46 �1 1 Phone 3� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES I -- DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL Pf+S/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of!Nell Excavation'_-' - Dia.L Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type-of Casing ' } " .. Specifications <br /> ! <br /> ❑ Public C1 Other El Delta Depth of GrouSeal--- Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed:by <br /> Repair Work Done ❑ Type of Pump _S Ulm H.P. 1 State Work Done .��>� Ok <br /> Well Destruction LJ Well Diameter SLIing Material (top 50') t 5 _f-; <br /> Depth Filler,.Material (Below 501 a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is �- <br /> r available within 200 feet.l <br /> Installation will serve: Residence— Commercial— Other j f 1Jcil <br /> rI r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: F i Water table depth <br /> SEPTIC TANK ❑ T e/Mf 1— Ca-it <br /> YF� 9 - - ,. payNo. Compartments <br /> PKG. TREATMENT PLT. ❑ h�a,I � Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines i 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 i Foundation Property Line <br /> DISPOSAL PONDS ❑ s r <br /> hereby certify that I have prepared this application and that the work Vt ill 6e done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. I I I <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 following:"I certify that in the performance of the work for whic�bis permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." i { <br /> The applicant must for all requir d in ctions. Complete drawing on reve f ide. <br /> Signed:a = Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> I F <br /> Application Accepted by Date ' Aree <br /> �!s <br /> Pk ��1,or Grout Inspection by bate Final Inspection by_�� - Hate �s <br /> I <br /> Additional Comments: r <br /> ❑ Stk 466-6781 ❑ Lodi 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 /> I <br /> FEE AMOUNT DUE AMOUNT_REMITTED CK RECEIVED BY DATE PERMIT NO. S <br /> INFO c t �� rCASH <br /> + EH 13-24(REV.1/951 01-11 <br /> EH 14-28 g�— <br />