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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA } <br /> Telephone (209) 466-6781 r <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED <br /> (Complete .in Triplicate). Y <br /> hcation is <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 app <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 tfte:SanJoaquin <br /> Local Health District. i "y _ <br /> PN._ <br /> City Lot Size- ... <br /> Job Address LK4W .4 <br /> '"'� d - Phone <br /> Owner's Name & e, Address <br /> sf <br /> 2 � License No. S _2_ Phone i J <br /> Contractor's Name ' „ <br /> TYPE OF WELLIPUMP: �I NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ` SYSTEM REPAIR El OTHER ❑ <br /> _ IC TANK <br /> SEWER LINES DISPOSAL FLD. .PROP;,LINE <br /> DISTANCE TO NEAREST: SEPT <br /> FOUNDATION aAGRICULTURE WELL- ;OTHER WEL`t�__= ~-PITSISUMPS <br /> INTENDED USE - TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' s <br /> ❑ Industrial ❑ Open Bottom 11 Manteca Dia, of Well Excavation Dia. of Well Casing <br /> � Specifications <br /> '4bomestic/Privat ❑ Gravel Pack 11T Tracy Type of Casing <br /> Type of Grout <br /> ❑ Public ElOther ❑ Delta Depth of Grout Seal, <br /> ❑ Irrigation pprox. Depth V 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 50'1 — 0 , <br /> 1' Depth Filler Material (Below 501 <br /> i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION'D <br /> (No septiclable h in permitted if public sewer is <br /> Installation will serve: Residence Commercial_ Other <br /> ` ��. Number of bedrooms <br /> Number of living units: Water table depth <br /> � 'i <br /> Character of^soil to a depth of 3 feet:��- N- <br /> Capacrty No. Compartments <br /> SEPTIC TANK�f ❑ Type/Mfg Method 'of Disposal <br /> PKG. TREATMEhT'PLT. ❑ 'I! <br /> I bistance to nearest: Well Foundation Property Line <br /> Length of lines <br /> LEACHING LIN ❑ No. & Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> Number <br /> SEEPAGE PITS;'' 11 Depth Size Property Line <br /> SUMPS ❑ Distance to nearest: Well Foundation - " <br /> DISPOSAL PONDS. ❑ C <br /> 1 hereby certify that'I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state <br /> laws, and <br /> rules and regulation's of the San Joaquin Local Health District. <br /> Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work foruvhich this permit is issued, I shall not <br /> _employ any person in such mariner as to become subject to workman's compensation laws of California."Cont actors 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 /> l tion laws of Cali#orriia." ;R _ n. r <br /> The applicant.mu ';call for all raq ired inspections. Complete.drawn g oil re. _saside. <br /> Dater ` <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> PR or Grout Inspectrlon by Date Final Inspection by &Af5vam Date <br /> Additional Comments: <br /> ❑ Stk 466-.6761 El Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 fi385 ; <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, 5tk., CA 95201 <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH _ <br /> fi <br /> k }' <br /> +EK 13-241REV.10183) 7 5 .-S <br /> EK 14-28 <br />