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3 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> .p 1601 E:*HAZELn O14`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 /> .549 for sewage or No.1862 for well/pump and tfis�.Rules and Regulations of the San Joaquin <br /> made in compliance with San Joaquin County Ordinance No <br /> Local Health District. / ,,l <br /> Job Address <br /> C <br /> L S C]f t Size PM <br /> / 3 Phone �[ <br /> Owner's me Address � �Z (� <br /> Address License No./4 3 <br /> Contrac <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ e <br /> PUMP INSTALLATION ❑ T SYSTEM REPAIR P--' 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 /> s , <br /> ❑ Industrial ❑ Open Bottom Cl Manteca Dia. of Weil Excavation Dia. of Well Casing <br /> Specifications <br /> '❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing T of Grout I <br /> ❑ Public Cl Other ❑ Delta Depth of Grout Seal Type , <br /> ElIrrigation ---Approx. Depth I] stern Surfac Seal Installed by <br /> Repair Work Done P'�Type of Pump . H.P. — State Work Done <br /> 11;4 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t <br /> Depth f Filler Material (Below 501 's <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Q REPAIR/ADDITION ❑ DESTRUCTION ❑ iNo septic system <br /> tem emitted if public sewer is s 1 <br /> t <br /> Installation will serve: Residence Commercial Other t <br /> 0l`) <br /> k Number of living units: Number of bedrooms <br /> ! <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK L1 Type/Mfg Capacity No. Compartments <br /> j Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 11 Distance to,nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11D p h c Size Number <br /> SUMPS Q Distance to nearest: Well– Foundation Property Line <br /> DISPOSAL PONDS ❑ ttx <br /> hereby certify that reparedliis applicatin`and that the work will be done in accordance with San Joaquin county ordinances, state laws, end <br /> O <br /> rules and regu ons of the Joaquin Local–Health Districtl'° <br /> Home owne or licensed agent' sigflature•certifies the following: ")'certify that in the performance of the.work-for which-this•permitis,issued, 1 shall not <br /> signature <br /> employ an person in such man r as to becAme subject to workm w mpensat�o laws of California.".Gontrsct hisub'ect to workmanking or ' <br /> s 9ompensa <br /> certifies t fdllowing:-,'I certify ha the performan for ich ' per ' 'ssued,Lskiall empidy pe , + a 1 <br /> 4•, \,.. <br /> 6 tion laws of California." -•-''+ , <br /> + re i y ;» <br /> The appli nt must ca I1-r quired i cti G <br /> ate: <br /> Signed } <br /> t FOEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted b ol <br /> � �--�157 <br /> Pit or Grout Inspection <br /> Date ction by Final Insper Date s��-- <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 r <br /> Apelcant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 , <br /> t <br /> FEE CK RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> AMOUNT DUE —AMOUNT REMITTED CASH <br /> +EH 13-24 1 REV.1/5 5) <br /> EH 1428 <br />