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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 <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. <br /> /� ' f <br /> Job Address G J 2k�— ` <br /> -CaLcIlk -4 -City p ` Lot Size M <br /> Owner's Name` Is;` C Address <br /> Phone <br /> Contractor � � i 22 WnC=THftuAddress +� License NoV� hone <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 If Manteca Dia. of Well Excavation Dia. of Well Casing -- <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> ❑ Public Speci <br /> Other ❑ fications <br /> ❑ Delta Depth of Grout Seal Type of.'Grout <br /> Ll Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by to <br /> Repair Work Done ❑ Type of Pump <br /> H,P. State Work DoneT <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: R Idence_ --- Commercial— Other <br /> Number of living units: = Number of drooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK EL--Type/Mfg Ca aci <br /> p tY No. Compartments. <br /> PKG, TREATMENT PLT. ❑ .t Method of Df posaf <br /> Distance to nearest: WellFoundation Property Line <br /> LEACHING LINE L—ble, & Length of lines 3r Tot I length/size <br /> FILTER BED 11C�Distance to nearest: well "1-� •Foundation Property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well -_ Foundation <br /> DISPOSAL PONDS Property Line . <br /> ❑ <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 <br /> employ an permit is issued, I shall not <br /> P Y Y person in such manner as to become subject,to workman's compensation taws of California."Contractor's hiring or sub contracting signature <br /> ertifies the following:"I certify that in the performance f the'work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tio ws of Califo r <br /> The applic u t call all re ufred i cti d plate drawing on re rse side, <br /> Signed <br /> Title: } C <br /> l Date: <br /> f FOR DEPARTMENT USE ONLY <br /> Application Accepted by � a <br /> DateArea <br /> or Grout Inspection by Date r Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑•Manteca x'823-7104 ❑ 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 /> 'f r <br /> FEE a <br /> INFO AMOUNT DUE AMOUNT REMITTEDCK RECEIVED BY DATE PERMIT N0. <br /> + EH1 -24IREV.t/asl � (�y „-A i , <br /> EH 1426 <br />