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APPLICATION FOR PERMIT <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 i <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 /> � p •C <br /> Job Address —� –k t C L',D4 City Lb r' Lot Size aMYEL14 PM <br /> l �1.�Y� Phone <br /> Owner's Name '��U� � `� Address - <br /> Contractor CutAddress , ® l Aalpwicense No.430 X Phone <br /> ---TYPE OF WELL"/PUMP: """ NEW WELL-'[] '""" 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 PITS/SUMPS <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 <br /> ❑ Public O Other El Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation y,�-_approx. Depth ❑ Eastern Surface Seal Installed by • r <br /> Repair Work Done ' Type'of Pump H.P. State Work Done <br /> Well Destruction 6 Well Diameter Sealing Material (top 501 nf� <br /> Depth Filler Material (Below 501 <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION TRUCTION ❑ (No septic system permitted if public sewer is <br /> y available within 200 feet,) <br /> Installation will serve: Residence ommercial__ ther r <br /> Number of living units: ------ <br /> Number of Pedrooms <br /> Character of soil to a depth of 3 feet: r � I4� Water table depth <br /> SEPTIC TANK �:CypelMfg �.Gapacity .....�JU + No. Compartments <br /> 'PKG. TREATMENT,PLT. ❑ `– - Method of Disposal 'r <br /> ,. Distance to nearest: Well �Q Foundation_. S. Property Line <br /> LEACHING LINE 4---ff65. & Length of lines ToYl length/size ' <br /> FILTER BED ❑ Distance to nearest: Well . Foundation Property Line <br /> r <br /> SEEPAGE-PITS"' ' q;,0e­pth A-1 2 Number <br /> SUMPS . _w, ❑ Distance to nearest: Well 1L'� Foundation Property Line- <br /> DISPOSAL <br /> ine-DISPOSAL PONDS, ❑ ? r t f - r <br /> hereby certify that I have prepared this application'and'that the vaork will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. 11 �» . . ! __ <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'Calif ornia." Contractors hiring or-su'b-contracting signature <br /> certifies th ollowing: "I rtify 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 o rnia." <br /> Thee '�icani- List or all uire 'nspec iiiF m drawing on re rse side. ► �',� <br /> Signed Title: A Date: <br /> 1 FOR DEPARTMENT USE ONLY <br /> Application Accepted IVI n Date a r Area <br /> Pit or Grout Inspection by Date Final Inspection by/jzl� Dat <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-MM <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 RECEIVED BYDATE PERMIT'NO.' <br /> INFO C <br /> EH t&24(REV.f/a 57 f Q Q `�,'3^-� k-7 <br /> +,; <br /> EH..14-26 w 1 <br />