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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 TYEAR 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address __L 01 <br /> 5�19N City Lot Size PM <br /> N ,o� <br /> Owner's Name Ad_ �/ Address Phone Z <br /> Contractor Address Address icense No.� �Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <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 /> LI Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type e of Casing Specifications <br /> M Public 1-1 Other ❑ Delta Depth of Grout Seal Type of Grout _, <br /> Irrigation A <br /> —.. pprax. Depth i I Eastern Surface Seal Installed by ' <br /> Repair Work Done ❑ Type of Pump VB Ajh� H.P. State Work Done ,L_ hiF�e> <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material /top 501 <br /> Depth Filler Material (Below 501n <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted it 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mf <br /> g Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ElDistance to nearest: Wel! Foundation Property Line I <br />' * F SEEPAGE PITS ! l Depth Size <br />' - Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> E 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, ands <br /> rules and regulations of the San Joaquin Lo&il-Health_'District. t <br /> Home-owner or licensed agent's signature Eertifies 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 astito.become subject to work '" <br /> art laws of Califorriia.",Contractors(tiring or sub-contracting signature <br /> certifiei.the following: "I certify that in the perionliance of the work for which this permit is issued,I shall employ persons'subject to workman's compensa- <br /> '} tion laws of California." I <br /> {The applicant mu I squired S. s <br /> Complete drawing on rev a - i <br /> i Signed X Title:. Date:14 [4' leg 11 <br /> ( FOR DEPARTMENT USE ONLY i <br /> 1 , <br /> Application Accepted by t` -•�' t-� pate '���= e <br /> ' 5-Date. f y � I <br /> Pit or_Grout Inspection.by� __ _Final_Inspection b Dat , /ll1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 , ❑ Codi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <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 RECEIVED BY DATE <br /> C H PERMIT'NO. <br /> INFO <br /> a.EH 124 rREV.t i n 5Y ✓ /5Z7 <br /> EH 14-4-29 d <br />