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N <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 I <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City X.D� P� Lot Size PM <br /> Owner's Name 7_0 A it-ig g) J4 �.rlaclress Phone <br /> rs2 <br /> Contractor � '��'� ` �• Address���� kl���X License Nv. - Phone �I ��� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i <br /> ❑ Irrigation _.—Approx. Dept ❑ Eastern Surface Seal Installed by 4 { <br /> Repair Work Done ❑ Type of Pump �� H.P. State Work Done – I 'ce <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material {Below 50') 4 J <br /> 6 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) a <br /> Installation will serve: Residence_ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r0 <br /> LEACHING LINE ❑ No. & Length of lines 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 _Foundation Property Line <br /> DISPOSAL PONDS ❑ -. '• <br /> 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." Contractors 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." <br /> —� <br /> The applicantI f all r inspections. Complete drawing on r verse e. r. <br /> MV <br /> Signed Title: T� TC1 r Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by �` {° Date Area�� <br /> ate � '� Final Ins action b Date p, <br /> Pit or Grout Inspection by p Y <br /> Additional'Commehts: <br /> j ❑ 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 AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> CK <br /> INFO <br /> +EH 13-24 1REV.1/8 <br /> /a 51 1-x� " T{ —�C 7 <br />