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APPLICATION FOR .PERMIT <br /> �1 1 VI <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTj!,, <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 raL HEALTH <br /> I <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSU:Df1RC �lv <br /> ERM1T/ 'SRVICS <br /> (Complete in Triplicate) <br /> Q : <br /> p ? application is <br /> Application is hereby made to the San Joaquin Local Health District fora permit to construct and/or install the work herein described,This app" <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for wewpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> �o <br /> PM <br /> 1e� City .' r' <br /> Job Address AN I S ���6i? <br /> r /- s <br /> a.� " �� /��° Phone � <br /> Owner's Name l v Address e°/���Xse No.45p__q-57-3 Phone <br /> Contractor Address <br /> TYPE OF WELL PU NEW WELL D WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION. AGRICULTURE WELL OTHER WELL - PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> j ❑ Industrial LIOpen Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> t'1 Public D Other CZ Delta Depth of Grout Seal <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 /> i <br /> Sealing Material (top 50') <br /> L, Well Destruction L2 Well Diameter 9 <br /> Depth Filler Material iBelow 50'1 — Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION l i alvailable�within 200 feet.Isystem if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT" 17Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> FILTER BED ❑ Distance to clearest: Well Foundation Property Line <br /> SEEPAGE PITS I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well foundation Property Line <br /> -- <br /> �— DISPOSAL PONDS - ❑" '"" d. <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, an <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 shalt 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 which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." F <br /> The applicant must cal r all required inspections. Complete drawing,9n reverse 11de. <br /> Title: Date: <br /> Signed +� <br /> FOR.DEPARZMENT USE ONLY <br /> � Area <br /> i Application Accepted Date by / \ <br /> Pit or Grout Inspection by <br /> Date Final Inspection by `- Date f4 8 <br /> I 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 /> FEE CK RECEIVED BY PATE PERMIT NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> G �7 <br /> i + EH 13"241 REV.1/H5Y � _<3 <br /> EH 14-28' �, <br />