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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEILTON AVE., STOCKTON, CA <br /> Telephone 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ..F. �. (Complete in Triplicate) s Ile <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein describ his 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. <br /> a„ <br /> s � 7��7_ <br /> Job Address �1 City Lot Size PM <br /> 1AOwner's Name /&"o Address Phone <br /> Contractor's Name 'MIAYNIMS1" 4SLicanse No. Phone /` 3?_ <br /> TYPE OF WELL/PUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION 1-1SYSTEMREPAIR ElOTHE ❑ <br /> DISTANCE TOINEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDEDUSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> _ ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other C: Delta Depth of Grout Seal Type of Grout 14 <br /> 171Irrigation _—ApproJ Depth ❑ Eastern Surface Seal Installed by <br /> RepaiCork Done El Type of Pump H.P. St to ork Dgne <br /> Weil Destruction Well Diameter I Sealing Material (topC1 <br /> Depth d Filler Material (Belovl 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t available within 200 feet.) <br /> Installation will serve: Residence' Commercial_ Other <br /> 1 Number of living units: Number of bedrooms <br /> f Character of!soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANKType/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT. ❑ Method of Disposal <br /> * s Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> I <br /> FILTER,'BED r Distance to nearest: Well Foundation - Property Line <br /> SEEPAGE PITS a ❑ Depth f Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS _❑ <br /> I hereby certify',that I ha'U'e prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations v(fie San Joaquin Local Health District. <br /> Home owner'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 persons subject to workman's compensa- <br /> tion laws of Californias -; <br /> The applica r ust call'J&all required inspections. Complete drawing on�rreevelerse ide. <br /> Signed Title: Date: <br /> ' FOR DEPARTMENT USE ONLY <br /> Application Ac6epted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date - <br /> Additional Comments: - - <br /> ❑ Stk 4666781 C1L i 369-3621 ❑ Mateca 823- 04 ❑ 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 /> FEE <br /> I <br /> ' INFO AMOUNT DUE AM NT REMITTED CASH RECEIVED BY DATE PERMIY'NO- <br /> +EH 13.24/REV.19/83) - <br /> EH W28 <br /> l ,� , <br />