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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 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 <br /> Local Health District. <br /> Job Address !7-4 2 Z City See PM <br /> Owner's Name S Address �f z Z a� C Phone I <br /> Contractor sem_ u Address.JAn A q �rlicense No. 7 <br /> Phone 4&A-qivaA <br /> TYPE OF WELL/PUMP: NEW-WELL WELL REPLACEMENT DESTRUCTION <br /> PUMP INSTALLATION SYSTEM REPAIR [I OTHER 0 <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM"AREA CONSTRUCTION SPECIFICAT! <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation H Dia. of Well Casing <br /> IR'Smestic/Private D1iravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public C1Other E] Delta Depth of Grout Seal 54 Type of Grout <br /> ❑ Irrigation / --Approx. Depth ❑ stern Surface Seal Installed by <br /> Repair Work Done C� Type of Pump C-� H.P. ,c I . State Work Done <br /> Well Destruction lid Well Diameter It <br /> Sealing Material {top 50'1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if nZ;-Wr-is <br /> Installation will serve: Residence_ Comrnerciai_ Other available within 200 feet.) <br /> Number of living units: Number of,bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capec" No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑' No. & Length of Tota! length/size <br /> FILTER BED ❑ Distance sorest: Well Foundation Property Line <br /> SEEPAGE PITSi Depth Size Number <br /> SUMPS ❑ .. distance to nearest: Wel! Foundation Property Line <br /> DISPOSAL PO S b <br /> I hereby certify that I have prepared this Spplication and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regul the San Joaquin Local Health District. <br /> Home own or licensed a nt's signature certifies the foil ' g: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ a person in such nner as to became subje o w rkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies a following:"I certi at in the rf rm n of th work for which this ermlt is issued,I shall employ persons subject to workman's compensa- <br /> tion la, <br /> a of California." pensa- <br /> The ap icant or I require 'in ti o ete dra a side. <br /> Signed f le: r4 <br /> Date: <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date *LeaPit or Grout Inspection by Date Final Inspection by (� .Additional Comments: �v �3 �� LI (y �- �.G4 0 �cG ¢fig Y+ V <br /> 11 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8 Pi'+ 3 Q v11 �v <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT•NO. <br /> + EH11324 IREV.t i s 5)EH t4-28D l <br />