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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> _ Telephone (209) 466-6781 <br /> Y <br /> a 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 for sewage or No. 1862 for welltpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ` r <br /> U �tCit r"� <br /> Job Address Y Lot Size PM <br /> Owner's Name S I'& Address Phone <br /> Contractor��!_ Tr fir" `-`� )' _ Address ` License No.7? Ute«6 Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR O OTHE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE r <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE ;-TYPE OF WELL PROBLEM AREA CONSTRUCTION,SPECIFICATIONS 3 <br /> * Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public n Other Cl Delta Depth of Grout Seal Type of Grout-- <br /> I <br /> rout I I Irrigation —_Approx. Depth i I Eastern Surface..Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION,IT INo septic system permitted if public sewer is <br /> �-�- available within 200 feet.] <br /> Installation will serve: Residence— Commercial----7—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 f Capacity No. Compartments \ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> WA <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> F <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ 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 si ture certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Ik employ any person in c nn a to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifiesthe followin . "I at 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 a." <br /> The applicant mu ca spections. Complete drawing on reverse side. <br /> Signed X Title: vAXE Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byDate n Ar a <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Err 15 r4w fwa L NE <br /> ❑ Stk 466-6781 C3Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 fH 1( 1Q <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK It <br /> FEE AMOUNT DUE AMOUNT REMITTED CAS RECEIVED BY DATE PERMIT NO. <br /> INFOFV <br /> r EH 13-24(REV.t/H5) 5S7 <br /> EH 14-26 •' L <br />