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APPLICATION FOR PERMIT <br /> u <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name �el� _/� I �/t/C1��N Address % L�C 4 --._ !---�� Phone _ ✓ <br /> C (erg /.y�IP, _ <br /> Contractor Address emlo6geQ 445 f,,9< �i�' License No. Phone <br /> TYPE OF WELL/PUMP: '' NEW WELL E3 WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK_ SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL — PITSISUMPS <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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications j <br /> f'l Public n Other ❑ Delta Depth of Grout Seal Type of Grout 7 <br /> I I Irrigation --Approx. Depth i I Eastern Surface Seal Installed by <br /> Repair Work Done LiType of Pump H.P. State Work Done � �/010", <br /> VL <br /> Well Destruction Well Diameter Sealing Material I <br /> Depth Filler Material (Below 50') / <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I 1 INo septic system permitted if public sewer is� – <br /> available within 200 feet.I <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/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Disposal t <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of line', Total length/size; <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property.Line f <br /> r <br /> SEEPAGE PITS I I Depth * Size Number 4 <br /> SUMPS Ll Distance to nearest: Well foundation Property Line j <br /> j <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 county ordinances, state laws, and <br /> rules 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 is issued, I shall not <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 <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 [a require s. Complete drawing on reverse side. 1 <br /> Signed X Date: <br /> l <br /> i <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Date 'p` Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: J <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE �} PERMIT`NO. <br /> r.EH 13241pEV.rinse �5�.�r ` fs (�[ ^3a, <br /> EH 14-28 '�.J V <br />