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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 /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San JoaquinLocal Health District for 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 L(J I S , <br /> City Lot Size PM <br /> t � <br /> Owner's Name _� _ Address S . ,. ��C0 <br /> V Phone 9 , <br /> Contractor&M v L !"1 Address <br /> Al <br /> License No.a �/ / Phone ` ^! <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMEN7� <br /> DESTRUCTION <br /> PUMP INSTALLATION� L SYSTEM AEPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _ D SEEEINES 1�0. <br /> DISPOSAL FLD. PROP. LINE1� <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PITS/SUMPS <br /> ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Well Excavation ` <br /> ` <br /> Domestic/Private <br /> X'Gravel Pack ❑ Tracy Type of Casing Dia. of Well Casing <br /> Specifications f6 t! <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal rY <br /> El Irrigation / Jq Type of Grout <br /> pprox. Depth ❑ Eastern Surface Seal Installed by +5-'l --# <br /> Repair Work Done ❑ Type of Pump ___ H p <br /> Well Destruction ❑ Well Diameter _ r; State Work Done <br /> 6 Sealing Material (top 50') t <br /> Depth Filler Material (Below 50') �` I <br /> r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is � ( <br /> Installation will serve: Residence_ Commercial available within 200 feet.) 1 <br /> Other „ , . <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: _ f <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ } - � <br /> Method of Oisposai ' <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Q No. & Length of lines ., <br /> " Total length/size r <br /> FILTER BED ❑ Distance to nearest: Well Foundationf <br /> Property,Line- <br /> SEEPAGE PITSM .y^ <br /> ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation ' <br /> DISPOSAL PONDS ❑ _' - _Property-Line. __ _. <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-contracting 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 applicant must call for required inspections. Complete drawing on rev side. <br /> Signed Title: <br /> Date: 5-2 ,�— <br /> FOR DEPARTMENT USE ONLY <br /> Applicat' n_Accepted by pate <br /> Q� 1. 'Sflrtlt7llOzc�' <br /> Put or Grout Inspection by Date�� Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK Ot <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br />+ EH 1426-26 .S(REV. <br /> 14 <br /> EH +9 --7l3 <br /> � 6 �! 3 $=�l <br /> I <br />