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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. 1B62 for we111pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. '( <br /> Job Address Lot Size G S - PM <br /> Address <br /> owner <br /> owner's Name I J r <br /> Contractor Z& Address ' r License No.Qq Phone. <br /> TYPFn0 WELL-/-PUMP -ANEW-WELL; WELI-REP LAC EMENT-D - -DESTRUCTION,❑-- --•�»- - ". <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ J <br /> DISTANCE TO NEAREST:.SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINEc ? <br /> FOUNDATION n?=D_..-- AGRICULTURE WELL -OTHER WELL d0_-1' PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICAT_10 S ;: a- <br /> Cl Industrial OC-Open Bottom ❑ Manteca Dia. of Well Excavation ,. Dia. of Well Casing -� <br /> Domestic/Private El Gravel Pack L1Tracy Type of Casing 3 0 t Specifications <br /> M Public 71 Other Cl Delta Depth of Grout Sea! T pe of r <br /> I I Irrigation a __Approx. Depth 1 Eastern �5 ,race Sea! Installed by i <br /> i + r 1 <br /> Repair Work Done ❑ Type of Pump � H.P. State Work Done <br />� Well Destruction ❑ Well Diameter Sealing Material (top 501.,. <br /> � <br /> Filler Material (Below 50'1 °~Depth f <br /> TYPE-OF-SEPTIC WORK:-NEW INSTALLATION I 1 REPAIR/ADDITION.1.1 DESTRUCTION I I (No septic systert,permitted if public sewer is <br /> available within 200 feet.) O <br /> InstallaTz.tion will serve: Residence— Commercial Other <br /> Nurhber'-of living y`g units: Number of bedroom f <br /> t Character of soil to a depth of 3 feet:' Water table depth <br /> SETANK 171TypelMfg <br /> Capacity No. Compartments s ' <br /> r r <br /> "PKG.4TREATMENT PLT. ❑ Method of Disposa\ <br /> rl \`• Distance to nearest: Well ? "Fbundatiori Property Line <br /> AL V <br /> LEACHING LINE ❑ . No. & Length of lines ° t Total length/size' <br /> FILTER BED' ❑ Distance to nearest: Well Foundation Property Line <br /> $ r 1 4 <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS C1Distance 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 /> Homeowner-or_licansed agent-s•signature certifies-the-following:.44I-certify that-in-the-performance-of-the-worlr-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,t shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required ins ctions. Complete drawing on reverse side. <br /> 4 Signed X Title: '4:�­ Date: i <br /> _FOR DEPARTMENT USE ONLY <br /> f Application Accepted by Date b r Area <br /> ` Pit or Gra t in <br /> by f Date f Fina! Inspection by Date <br /> f Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ anteca 823-7104 Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 20W, Stk., CA 9,5201 , <br /> FEE AMOUNT DUE AMOUNT REMITTED y D SHS RECEIVED BY DATET� PERMIT NO. <br /> INFO _ <br /> +.EH 13-24(REV.1/M!D <br /> EH 14-26 <br />