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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 /> f , (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.,w <br /> City Lot Size PM <br /> Job Address <br /> i <br /> Owner's Name Address; f 4 Phon <br /> a Lin& vN <br /> Phone, <br /> License Contractor's Name I <br /> TYPE OF WELL/PUMP: NEW WELL_❑ WI Ll-REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION F-1 ' rs, SYSTEM REPAIR 1:1f OTHER 13 f <br /> DISTANCE TO NEARES S PTIC TANK �' SEWER LINES y DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS s <br /> INTENDED USE .-- <br /> —"'TYPE OF WELL PROBLEM AREA _CONSTRUCTION SPECIFICATIONS ; <br /> ❑_Industrial ❑ Open Bottom ❑ Manteca Dia. of Wel! Excavation Dia. of,WeklssCasing <br /> ❑ D'o'mestic/Private ❑ Gravel Pack E3 Tracy Type of Casing__ .�Specificatroi <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal �- Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Stat Work Done <br /> Repair Work Dane © Type of Pump H P Qlal' <br /> �+ x <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 s I <br /> Depth Filler Material (Bel w 501). I s <br /> +*" TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION _ DESTRUCTION ❑ INo septic system permitted if public4!w,eL is �}`S <br /> .4 q, available within 200 feet.) <br /> # <br /> Installation will serve: Residence_ Commercial X Other C <br /> l <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of'soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Capacity _ No. Compartments <br /> i PKG. TREATMENT PLT. ❑ k Method of Disposal T <br /> Distance to nearest: Well'.':�' ``•Foundation Property Line <br /> - I � <br /> LEACHING LINE ❑ No. & Length of lines Q `✓— ' tal length 11 <br /> e. <br /> FILTER BED Distance to nearest: well Foundation al Property Line _ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ f <br /> 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. P 1— <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 /> ,workrnan's come <br /> California." Contractor's hiring or sub-contracting signature,- <br /> employ any person in sudh manner as to become subject tocertifies 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'app <br /> t caU for all require in pections. Complete drawing on reverseeiide. `� <br /> 9 <br /> 'Si reed Title: � �J 7� � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date K <br /> Additional Comments: �� <br /> ❑ Stk 466-6781 ❑ Lodi 389-3521 El Manteca 823-7104 CI Tracy`-835-6385_ x ,Qr , , ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601'E. Hazelton Ave., P.Oc-Boz 2008;Stk., CA 95201 <br /> ` FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> ,INFO- <br /> + <br /> ; <br /> .. <br /> +EH 5324 TREY.10/63A <br /> EH 14-26 <br />