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f <br /> ---�j° APPLICATION FOR PERMIT <br /> f SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA n� , ws <br /> Telephone 12091 466-6781 <br /> t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (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 R <br /> Local Health District. egulations of the San Joaquin <br /> Job Address xd KCit�/� rP- Lot Size, " PM <br /> w I <br /> Owner's Name AFAA 1 Address :3 ����T 4P)'tW '4V Phone <br /> Contractor Address License No. Phone_ <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION D <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> r SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑. Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private C1 Gravel Pack ❑ Tracy ,Type of Casing Specifications <br /> FI Public 1=1 OtherF1Delta - Depth.of-Grout*Seal ,:Type of Grout _ <br /> I I Irrigation �_-Apprax. Depth l I,Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P.­ x State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [] REPAIR/ADDITION ( I DESTR ON f I (No septic system permitted it public sewer is <br /> available within 200 feet) S <br /> Installation will serve: Residence NJ Commercial -t•Other <br /> Number of living units: Number of bedrooms "y- <br /> Character of soil to a depth of 3 feet: Water fable depth <br /> SEPTIC TANK ❑ Type/Mfgs Capacity/_ No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal i <br /> f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Tota! length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f I Depth Size <br /> 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 countyordinances,`stale llaandrules 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 s'issued, I employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting sg <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 fqr all required inspections. CQrnplete drawingr"on reverse side. <br /> Signed X <br /> Title; _ pats: <br /> r <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Dater Ar U <br /> Pit or Grout Inspection by Date Final Inspection by Dat <br /> � I <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi M621 �0Manteca 623-7104 © 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 <br /> INFO RECEIVED BY DATE EERM111'EH 13•x4/REV.�/N 51 y r,EH t4-26 <br />