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__"ECJ <br /> IVE�1 ' <br /> ` APPLICATION FOR PERMIT <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT NOV } � <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> ENVIRONMENTAL HEALTH <br /> t <br /> Telephone (209) 466-6781 PERMIT/SERVICES <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ) <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 wefl/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ro city Lot Size <br /> PM_ <br /> Owner's Name ?iL(�'' Address i 7/1 /`�""�" � �� <br /> Phone <br /> i Contract Address ��,License Ivo. 42- 3�=Z&� <br /> Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑--­� t - WELL-REPLACEMENT El DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIR OTHER ❑ <br /> x DISTANCE TO NEAREST: SEPTIC,TANK SEWER LINES <br /> _-- _ DISPOSAL FLD. PROP. LINE <br /> FOUNDATION _ <br /> AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca sa Dia. of Well Excavation <br /> y_ Dia. of Well Casing <br /> ywomestic/Private ❑ Gravel Pack r { ❑ Tracy Type of Casing <br /> Specifications <br /> I`i Public (7 Other ❑ Delta * �'—'bepth of Grout Sea[ — <br /> IType of Grout <br /> I Irrigation <br /> g" �-Approx.,Depth 1 1 Eastern Surface Seal Installed by <br /> Repair Work Done $1 Type of Pump H.P. ,0_ State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material flop 50'1 r <br /> t Depth Filler Material (Below 50') O <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I1 DESTRUCTION I I IN septic system permitted if public sewer is <br /> Instal lation will serve: Residence Commercial_ Other available within 200 feet.] <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: I f` a <br /> SEPTIC TANK ElT 1 Water table depth ° <br /> Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ I l <br /> Method of Disposal <br /> Distance to nearest: Well Foundation a Property Line <br /> LEACHING LINE ❑ No. & Length of lines r. x <br /> ' Total length/size <br /> FILTER BED ❑ Distance to'nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth 1 Size <br /> SUMPS <br /> Number <br /> ❑ Distance toynearest: Li <br /> r Welf <br /> -- Foundation Property Line <br /> Df5POSAL PONDS ❑ � - '�"'�^"-'-^�- �--' '•'+ <br /> I hereby certify that I have prepared this application and that the work will he 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 t <br /> tion laws of California." t p Y persons subject to workman's compensa- <br /> tion <br /> applicant et-call. r all required ins ctions. Complete drawing on reverse side. <br /> Signed X g <br /> Title: Date: • <br /> �T/ _ FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ Date /1 ! ��Im <br /> Area <br /> Pit or Grout Inspection by ° Date Final inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 /> NF AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 13-28(REV.l i n 51 [j <br /> EH 11-28 <br />