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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ■ �` City of Size PM <br /> qtnsOwner's Name S Address 1 ne <br /> I � ` <br /> Contractor ddress License No.V No. I hone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION I❑ je <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ���.Ya �at�y� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PLO. PROP. LINE <br /> —T FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION 5PW1F€CATIONS—_- _-0 t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type ofiCasing a Specifications <br /> D Public ❑ Other ❑ Delta Depth of Grout Seal r r Type of Grout ` G, <br /> ❑ Irrigation ---Approx. Depth -,❑ Eastern -Surface Seal-Installed by''�"" " ` ,�- <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done 1 <br /> Well Destruction ❑ WellDiameters Sealing Material (top 50') � { <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if-public sewer is r <br /> r available within 200ifeet.)'- <br /> Installation will serve: Residence_ Commercial_ Other r <br /> Mumber of living units: �`� Number of bedrooms 9 <br /> p <br /> Character of soil to a depth-of 3 feet: Water table depth iS <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments_' <br /> PKG. TREATMENT PLT. ❑~` �-�� Method of Disposal <br /> r i l <br /> Distance to nearest: Well Foundation" Property Line <br /> LEACHING LINE ❑"No. & Length of lines Total length/size <br /> FILTER BED ❑ .,Distance to nearest: Well Foundation ,why Property Line <br /> tw <br /> SEEPAGE PITS w " ❑€:.Depth Size <� Number 1 w <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> �` <br /> DISPOSAL POND ' .;'. w Yom. ".._�,, ` it14.:'- <br /> S17 - <br /> I 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 Sbn Joaquin Local Health District. + r L <br /> Home owner or licensed agents signature certifies the following: "I certify that Wthe performance of the work for which this permit is issued, I shall not <br /> employ any person in such maorner as to become sub j t to workman's compensation laws of California."Contractor's hiring or sub contracting signature <br /> certifies the following: "I rti that in the performa e o he work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Californi i <br /> The applicant mu for all required in S. a drawing onrse-side <br /> Signed X Title: at <br /> FOR DEPARTMENT USE ONLY <br /> Application c ted byDate Area <br /> Pit or Grout Inspection by Dater v0��Finalelnspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369.3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO, <br /> INFO /� ! <br /> + EH 1324(REV.1/5-1 5) �V � � t <br /> EH 14-26 �� l G�f+ 4.A t <br /> " O "1 zs <br />