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1 4 <br /> y APPLICATION FOR PERMIT <br /> 3 SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> j 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. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> i, Local Health District. ' <br /> j Job Address V ""+ ���y� R–ri City A�lC- Lot Size PM <br /> Ag— <br /> Owner's <br /> _/ <br /> Owner's Name —__ �' Address G`�eZ y 7`"" L _ Phone <br /> Contractor's Name ,.: S License No. _ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION.1K <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ❑ <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 /> ❑ Industrial E Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy t Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx..Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑, Type of Pump IF, H.P. mate Work Done <br /> Well Destruction Well Diameter eating Material (top 50') "/ V <br /> IF t+_' Depth Filler Material (Below 501 <br /> TYPE OF'SEPTIC-WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> _... �- available within 200 feet.) <br /> Installation will serve: *Residence�I Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> `Character of soil to a depth of 3 feet: Water table depth <br /> fff SEPTIC TANK ❑ Type/Mfg Capacity .,No. Compartments <br /> PKG:TREATMENT PLT. ❑ Method of Disposal ry{ <br /> M,Distant;e to nearest: Well Foundation Property Line j �f <br /> LEACHING LINE El '&& Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS b_ - ❑_Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sart Joaquin county ordinances, 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 per' '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 <br /> �� fY pe P p 1 laws of California." <br /> The applican st call for all required inspections. Complete drawing on reverse side. <br /> i <br /> Signed X � —� Title: ( �tQ .. Date: zT�7 <br /> I FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Z Date Area <br /> Pit or Grout Inspection by " Date,46 Final Inspection by Date <br /> Additional Comments: f <br /> r ❑ Stk 466-6781 0 Lodi 36&3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E, Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE f INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 4-28/REV.101591 <br />