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t 7-, <br /> i 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 TYEAR FROM DATE ISSUED <br /> IComplete in'Triplicate)- t <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. ( _ I <br /> Job Address City Lot Size PM <br /> Owner's Name Add�re�ss� <br /> J - <br /> C�k VQ Phone <br /> ContractorQJ <br /> . Address License No. Phone <br /> 4 <br /> TYPE OF WELL/PUMP:: NEW WELL C7 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM-REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP, LINE. <br /> FOUNDATION AGRICULTURE WFLL 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 /> 0 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`t Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout-—­ <br /> I I Irrigation —.Approx.IDepth ( I Eastern Surface Seal installed by �+ <br /> .Repair Work Done �❑ Type of PumpH.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> • Depth I Filler Material !Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION t I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet./ <br /> Installation will serve: Residence, Commercial= Other <br /> Number of hiving 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 /> I <br /> PKG. TREATMENT PLT. ❑ } Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> e <br /> LEACHING LINE ❑ No- & Length of lines Total length/size <br /> FILTER BED �" d EJ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well t ._Foundation Property Line <br /> DISPOSAL PONDS ❑ r ,; <br /> I hereby certify that t 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 Diltrict. <br /> Home owner or licensed agent's signature certifies the following: "f certify that in the performance of the work for which this permit is issued, !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 !pec"' <br /> The appiica t c or r e i s. Com to drawing on reverse side. <br /> X r <br /> Signed Title: <br /> _ Date: <br /> FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by � <br /> Date rea <br /> Pit or Grout Inspection by Date Final Inspection by Date7 � <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ 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 /> I <br /> iE <br /> FEE AMOUNT DUE + AMOUNT REMITTED RECEIVED BY <br /> INFO GASH DATE PERMIT'NO. <br /> t <br /> ♦.EH 13-24(REV.rix51 <br /> EH 74-2e rJ <br />