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i <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM MATE 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 for sewage or No. 1862 for.well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ' <br /> Job Address " "^Y ���'�Gfi✓t AvSG x 0 0 <br /> City_ Lot Size PM <br /> ,u- �(,� <br /> Owner's Name ! Address / r U G` ! [� Si Phone -26 <br /> Contractor Address License No. Phone <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 FLO. 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 o6Grout Sea] Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done R"] <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <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 /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments `� r <br /> y „- ne <br /> PKG. TREATMENT PLT. F-1Method of Disposal <br /> Distance to nearest: Well Foundation """Property L1ne <br /> s <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."Contractor's hiring or sub-contracting.signature <br /> certifies the followin •"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 Califor ." �-�+�- """ •- <br /> The applicant ca for al q 'ad ins Complete drawing on reverse side. <br /> x Signed Title: Dat: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date <br /> Area <br /> Pit or Grout inspection by/� Date Final Inspection byc2dDates:j <br /> Additional Comments: f f <br /> ❑ Stk 466-6761 ❑ Lodi -3621 ❑ Manteca A234104 ❑ racy <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 AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.I/s sl <br /> ' EH 14-28 C?O -E7'-S <br />