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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 160.1._E._,HAZEL TON.-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 far'sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. r^ <br /> Job Address City e PM <br /> Owner's Name i�Q +�pes 2- 3� / (� �� Phone a� <br /> 7 <br /> Contractor <br /> ILP-1. .�'`L ddress ` �- License No. hone 6 6-�d <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 ElOpen Bottom C1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> GYDomestic/Private © Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation L—Approx. Depth ❑ astern Surface Seal Installed by <br /> Repair Work Done IX Type of Pump � H.P. State Work o Done <br /> Well Destruction ❑ I <br /> We I Diameter SealingMateri I _ <br /> _ _. a (top 50'1_. _ <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> =,available.within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other -� <br /> Number of living units: Number of bedrooms <br /> r -' F <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. ❑ a �� Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i '': 1: <br /> LEACHING LINE 0 No. & Length of linesL _ T Total length/size <br /> FILTER BED ❑ Distance to nearest: Well + Foundation Property Line <br /> SEEPAGE PITS ❑—Depth---— .—Size- .Number..- + VJ <br /> SUMPS w❑ 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 regul soft San Joaquin Local Health District. <br /> Home own r licensed ag nt's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> eKperson in such anner as to b ome subj workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> cfollowing:"I that in th rform a the wor i this permit is issued, I shall employ persons subject to workman's compensa- <br /> tiCali rnia 'T t for all r u- Comple drawing on rSTitle: Date: '— <br /> FO PARTMENT USE ONLY <br /> .Application Accepted by Date Area <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: IWO /d <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.siesl <br /> EH 1428 <br />