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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> +; Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> 1-1 (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 Joan in <br /> Local Health District. ILII <br /> Job Address "l<-7 — City Lot Sire ` PM ly <br /> Owner's Name / ^Address / Phone ��]] <br /> ' �5 tJl3°pr. <br /> Contractor a��—C'�'J Address_ ___ -— Lic s � Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION;❑ ; SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTUREWELLOTHER 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing j' _ Specifications <br /> 1`I Public n Other ❑ Delta Depth of Grout Seal • Type of Grout \' <br /> „ 1,1-Irrigation ,,_.Approx..,Depth --_{ I Eastern-,.._,.Surfaee,Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. ,State Work Done' .: <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') ' <br /> - ` -Depth Filler Material (Below 50') I • ` <br /> TYPE OF SEPTIC WORK: NEW INSTAL ATION I l REPAIRIADDITION l DESTRUCTION [ I.(No septic'system permitted if public sewer is <br /> /f available within 200 feet.] <br /> Installation will serve:twResidence— Commercial_ ther . <br /> Number of living units: Number of bedrooms <br /> Character of sorl'til idepth-of 3 feet:_ - -- Water table depth <br /> SEPTIC TANK'" ❑ Type/Nlfg� ]Capacity` °"No. CompaiYmenis' ��' <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � . . <br /> LEACHING LINE ❑. No. & Length of lines Jotal length/ <br /> size <br /> FILTER BED. ❑ Distance to nearest: Well Foundation Property Line T� <br /> SEEPAGE PITS 11 Depth 1 Size Number "74 3 <br /> SUMPS ❑ Distance to nearest: We11 Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> } I hereby certify Ithat I have prepared this application and that the work will he done in accordance with San Joaquin_county_ordinan_ces, state laws, and <br /> ! rules and regulations of the San Joaquin Local Health District. <br /> Home owner or 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 manne;as to become subject to workman's compensation laws of -foril Contractor's hiring or sub-contracting signature �y <br /> certifi*plicaim <br /> ng: "I ce in the performance of the work for which this permit is i e , I s ! mploy persons Subject to workman's compensa <br /> tion lania." v+i <br /> T._The aall o al quir ins rawi on siSigne /��Title: Date:FO PA T NT SE ONLY <br /> Appliced by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date . 1211 <br /> ,s,Additional Comments: <br /> ❑ Stk 466-6781 ❑.Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Appiicant - Return all c res to: Environmental Health Permit/ ervices 601 E. Hazelton Ave., P.0 Box 2009 Stk., CA 9,520 <br /> FEE AMOUNT DUE =AMOUNT, k CASH 'RECEIVED BY DATE PERMIT'NO. <br /> INFO �n '7 r+� <br /> Ell Y <br /> 13-2-4(REV.1/K5] -70 ' 0 il 13 V0 1-2- ^Pd N>-tom <br /> EH 14-26 <br />