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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (200) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM' DATE ISSUED "x <br /> L 4; (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.` t l `a <br /> 1.�, <br /> Job Address City Lot Size , PM <br /> Owner's Name -Address, - - Phone �d�T <br /> l Contractor 1 res s y e�e No.f Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL"REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ r SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> s FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE "TYPE OF WELL PROBLEM AREA'J a CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca k 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 SealType`of <br /> _ -Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by y ` <br /> Repair Work Done ❑ Type of Pump H.P.. tState Work Done <br /> Well Destruction Cl Well Diameter Sealing Material Itop 561 <br /> Depth I Filler Material (Belo 50'1 j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve. Residence Commercial_ Other <br /> I Number of living units: Number of bedrooms ` <br /> r Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK. ❑ Type/Mfg # Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 ' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size Lf <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line -� <br /> SEEPAGE PITS ❑ DepthSize 0 ° Number p+r. �0 <br /> ❑ .Distance to nearest: .Well 11L*)f_? Foundation .Property-Line -.. .. - <br /> - <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. r ! <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 followingi"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 applicant, ustall for all re d inspections. Ca plate drawing on r erre side. <br /> k + � <br /> Signed 7 Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted Date b""3 k, Area <br /> Pit or Grout Inspection by "- Date Final Inspection by Date <br /> Additional Comments. <br /> ta� <br /> ❑ Stk 466-6781 ❑ L r "❑ Ma eco 823-7104 ❑ Tracy-835.63% J <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 96201 &/I <br /> t <br /> FEE AMOUNT DUE AMOUNT REMITTED s CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +'EH 13-241REV.i/asl _7b OQ Wit_ <br /> r EH 14-28 6 �+v <br />