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a <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �vs <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> _ U <br /> Telephone (209) 466-6781 gy�pp'°" J,� <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) t <br /> Lit <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work�rM desc`nbed.-Ths application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rule11Rkai"' lations jtthe San Joaquin <br /> Local Health District. <br /> C <br /> Job AddressJJ City Lot Size PM <br /> Owner's Name l7 -'Address Phone <br /> Contractor l Addressll(tL� s .�s� �3�eicense No. Z Phon F <br /> TYPE OF WELL/PUMP: NEW WELL ❑ {WELL'lEPLACEMENT ❑ DESTRUCTION ❑ —� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> XDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> I i Irrigation "Approx. Depth l I Eastern Surface Seal Installed by �. <br /> Repair Work Doneti( Type of Pump H.P.-4tw'0 State Work Done 040V AaA"qw <br /> Well Destruction ❑--WellDiameterSealing Material (top 501 <br /> Depth k.. i Filler Material (Below 501 <br /> TYPE OF•'SEPTIC WORK: NEW INSTALLATION]"I REPAIR/ADDITION I I DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> "R ""�✓ available within 200 feet.) w <br /> Installation will serve: Residence— Commercial Other <br /> ' W <br /> Number of living units: .? Number-of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> jr-SEPTIC TANK ❑"'Type/Ntfg ' ` Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ 4 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size f <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> !i £ i <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 appkatiori 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 Di$trict. f <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 which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." r <br /> The applicant II for all required inspections. Complete drawing on r erse side. <br /> i. Signed C Title: Date: <br /> it <br /> c F DEPARTMENT USE ONLY A <br /> Application Accepted by Date rte` Area G <br /> I� <br /> Pit or Grout Inspection by Date Final inspection by ��"` Date " <br /> I! <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi369-3621 ❑ Manteca 1123-7104 EI Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2409, Stk., CA 95201 y <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PER No. <br /> u <br /> t.EH13-241REV.i/)i51 l f <br /> EH 14-2a / UT' -17J <br /> '.i <br />