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y ..I�,•vY� �• f <br /> x APPLICATION FOR PERMIT <br /> SAN JOAQ.UIN LOCAL HEALTH DISTRICT <br /> i <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <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 weN/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ! <br /> ' Lot Size R PM <br /> O� City <br /> Job Address <br /> iZ Address y' u Phone – a <br /> Owner's Name <br /> � f - IF4 r <br /> cense No.`� r _Phone <br /> Contractor's Name j � ___ <br /> �7 TYPE OF WELLIPUMP: NEW WELL WELL REPLACEMEN DESTRUCTION ❑ <br /> PUMP INSTALLATION rD SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _'�/^^O1,,�11�� SEWER LINES .1� DISPOSAL FLD._ZOO r PROP. LINE <br /> FOUNDATION �l1r�C� AGRICULTUREWELL/�66 OTHER WELL L� PITS/SUMPS 70A}E <br /> INTENDED USE TYPE OF WELL PROBLEM-AREA CONSTRUCTION.SPECIFICATIONS S �� <br /> El Industrial 11Open Bottom ❑ Manteca �. Dia. of Well Excavation Dia. of Well Casing <br /> Type of Casing Specifications <br /> Domestic/Private Gravel Pack ❑ Tracy Yp A- 9 - <br /> a ❑ Other ❑ Delta Depth of Grout Seal Type of Grou <br /> Public <br /> ❑ Irrigation . Deep�th� ❑ Eastern � Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pumps H.P. % State Work Done rl <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> Depth <br /> Filler Materiai (Below 501 c n <br /> �J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION C1REPAIR/ADDITION ❑' DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) C <br /> Installation will serve: Residence— Commercial Other �I <br /> Number of living units: Number of bedrooms <br /> ` Character of soil to a depth of 3 feet: Water table depth — -- . <br /> SEPTIC TANK. ❑ Type/Mfg Capacity No. Compartments f - <br /> F1Method of Disposal <br /> PKG. TREATMENT PLT. <br /> r Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines. <br /> Total length/size <br /> LE Q <br /> FILTER BED ❑ Distance to nearest: WeH Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 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 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 Califor <br /> The applicant mu call for all required ins cans. Complete wing.on reverse side. <br /> Title:' - Date: K <br /> Signed ! <br /> FOR DEPARTMENT USE ONLY <br /> Area <br /> l: Application Accepted by - <br /> { Date <br /> ate YI Final Inspection by ate <br /> Pit or Grout Inspectign by <br /> r <br /> Additional.Comments: <br /> ❑ Stk 466 6761 ❑ Lodi 369-3621 ❑ Manteca 71 Tracy 83x6385 r <br /> O. Box StkCg�Y <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P. ., A 95201 <br /> K RECEIVED BY DATE PERMIT'ND. <br /> i IFEE NFO AMOUNT DUE AMOUNT REMITTED H <br /> .� <br /> 4. EH 13-24IREV.101831 u <br /> ' EH 1426 <br />