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5 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> II <br /> Fi <br /> Telephone 1209] 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 /> i made in compliance with San Joaquin County Ordinance No. 549 for sewage or Na. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address. 1 �` J City <br /> Owner's <br /> Lot Size PM <br /> Owner's Name r "�'� -<`.0Address :' '���� <br /> ( Phone <br /> I Contractor %G d-°� Lam . �C�Addres 't`6 icense No %l lam" Phone <br /> F, <br /> TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT F1 DESTRUCTION Elt PUMP INSTALLATION;X SYSTEM REPAIR ❑ OTHER L],' <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 /> r #' ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> II I`] Public Cl Other Cl Delta <br /> F <br /> Depth of Grout Sea! Type of Grout _ <br /> I I Irrigation _,-Approx. Depth I I Eastern /Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pump--J,.- — H.P. `� _ State Work Done• !r7 1 f <br /> Well Destruction C7 Well Diameter Sealing Material (top 501 <br /> h Depth Filler Material (Below 50') L <br /> TYPE OF SEPTIC WORK; NEW INSTALLATION i 1 REPAIR/ADDITION I I DESTRUCTION 111No septic system permitted if public sewer is' <br /> available within 200 feet.) <br /> i Installation will serve: Residence Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> P Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i iPKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> 4- <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I ! Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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. <br /> r�. 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: "9 certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's com ensa-: <br /> lion laws of California. <br /> j p <br /> The applicant must call for all required <br /> PP e_q inspections. Complete drawing orreverse side. <br /> Signe /T Title: / l _._"-_ Date: _ Cv <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by A <br /> �^ Date Area <br /> F, Pit or Grout Inspection by Date Final Inspection by ` Date j c 47 <br /> t F , <br /> r <br /> r Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-31521 ❑ 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 95.201 <br /> FEE INFO AMOUNT DUE - AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT NO, <br /> �EH 1 -24(REV.r i y 51 <br /> -�1 EH 1 <br /> 4 4-26 <br />