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APPLICATION,FOR PERMIT <br /> SAN JOAQUIN i0.CAL*HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.; STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED,. <br /> (Complete in Triplicate); ... . 1 -141.715 I...,i,• <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-"':`�49 fnr sewage or,No. 1862 for well/pump and the Rules acid Regulations of the San Joaquin <br /> Local Health District. v C wh"P, <br /> Job Address City Lot Srzei r <br /> PM <br /> Owner's Name Address` r � <br /> Phone <br /> N <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA SYSTEM REPAIR ❑ OTHER ❑ f <br /> DISTANCE TO NEAREST: SEPTIC TANK R LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> 7AGRICU WELL <br /> OTHER WELL PITS/SUMPS p <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONS ION.SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia..of Well Exca Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type o g _ Specifications <br />" <br /> Cl Public ❑ Other ❑ Delta" epth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx.'Depth ern ,. - Surface Seal Installed by 1 <br /> Repair Work Done ❑ Type of Pu H. <br /> P. State Work Done <br /> Well Destruction ❑ iometer Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.► <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 <br /> SEPTIC TANK ❑ Type/Mfg. Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of"lines � Total length/size ' <br /> FILTER BED Ll Distance to nearest: Well Foundation Property.Line <br /> SEEPAGE PITS ❑ Depth { Size Number <br /> SUMPS. 0_ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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, 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." Contractor's hiring or sub-cobtracting 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 /> The agLIlLcant must call for all required inspections. Complete drawing on rse side. +� �`f <br /> e <br /> Signed X Title: <br /> Date: 1 <br /> — <br /> R PA NT USE ONLY k <br /> i <br /> i Application Accepted byA Date <br /> 7 ' Area t 3 <br /> Pit or Grout Inspection by Date Final Inspection by DatV_, f <br /> Additional Comments: <br /> w <br /> ❑ Stk 466-6781 ID Lodi 369-3621. . ❑ Manteca 823-7144 - Cl 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 INFO AMOUNT DUE f AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24(FiEV.s/a 5) n5 _d�r/) _ <br /> EH 1428 S•, �'0 � 1� �7�'77 .� <br />