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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 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address <br /> t� ` <br /> N / G <br /> City �- Lot Size PM <br /> Owner's Name ��� _ Address <br /> Phone <br /> Contractor's Name12..FiJLLF,Qr License No. <br /> TYPE OF WELL/PUMP:..'. .. -. Phone <br /> -NEW WELL.❑.�.. WELL-REPLACEMENT ❑. - . - .-.DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ y <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLOTHER WELL <br /> •" PITS/SUMPS <br /> INTENDED USE TYPE-OF WELL' <; PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom. Manteca Dia. . <br /> of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private-! D-Gravel Pack -0 Tracy T <br /> ❑ Public Ype of Casing Specifications <br /> ❑ Other i p Delta Depth of Grout Seal <br /> ❑ Irrigation -LApprox.-Depth ❑`Eastern - Type of Grout . <br /> Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H p y <br /> Well Destruction ❑ Well Diameter State Work Dane. <br /> Sealing Material {top 50') <br /> I Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION'❑, REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public' <br /> sewer is <br /> l `' -" - ,,yy= r � *K�~ y ,,-T ..available within 200 feet.) <br /> Installation will serve. Residence f!,' - ' <br /> Commercial_ '`Other _ <br /> Number of living units: _ Number of bedrooms l y <br /> Character of soil to a depth;of 3 feet: <br /> SEPTIC TANKWater table depth <br /> V <br /> Type/Mfg Capacity-41"0-11 No. Compartments <br /> PKG. TREATMENT'PLT. ❑ 4 <br /> Method of Disposal �I <br /> Distance to"nearest: Well 0860-An Foundation 107 Property Line <br /> LEACHING LINE No. & Length of lines � /�T <br /> i <br /> T ) length/size F r� <br /> FILTER BED ❑ Distance,to nearest_` Well Foundation� Property Line <br /> SEEPAGE PITS -' ❑`�Depth ` �T Size X V 7 <br /> SUMPS Number <br /> d 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 Jpaquin county ordinances, state laws, and f <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: } <br /> "I certify that in the performance of the wark.'for which this permit is issued, t shall not a <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 f <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, <br /> tion laws of California." I shall employ persons subject to workman's compensa- <br /> The applicant must call fo all re uired inspections. Complete drawing on reverse side. <br /> Signed . Title:_ . <br /> Date: <br /> FOR DEPARTMENT USE`40NLY <br /> Application Accepted by tk <br /> Date "Area <br /> Pit or Grout Inspection by Date Final Inspection b d <br /> [[ <br /> Additional Comments: Date <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca W-7104 ❑ Tracy 835-6385 { <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009­Stk., CA 95201 M <br /> FEE' AMOUNT DUE AMOUNT REMITTED CK#' - - <br /> INFO CASH RECEIVED BY y- DATE _ PERMIT No. <br />+EH 1426'REV.10Ll <br /> LJ S, e <br />