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Ile, <br /> of pwe�rlIle, s c <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT & <br /> 1601 E. HAZE 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 Rulesend R atB*ns of the San o7uuin <br /> Local Health District. / <br /> City rl I U AJ Lot Size �'S PM <br /> Job Address <br /> A- Address <br /> / ,,, Phone <br /> Owner's Name z <br /> Contractor <br /> .{ ddress License No. �1G'/� <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLA�TION <br /> „ , ' SYSTEM REPAIR Ll OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK r` SEWER LINES 10006 DISPOSAL FLDA/ / PROP. LINE �� e <br /> FOUNDATION U� AGRICULTURE WELLICAL1 OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> , C1 Tracy Type of Casing <br /> _!C-�� �T r� Specifications <br /> Domestic/Private kGravel Pack <br /> 71 Public C] Other 171 Delta Depth of Grout Seal Type of Grout <br /> r” <br /> ❑ Irrigation ---Approx. Depthn ❑,Eastern Sura a Seal Installed by 1 <br /> Repair Work done Type of PumpLbc�J <br /> H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ltop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ available septic system <br /> m emitted if public sewer is rJ <br /> Installation will serve: Residence, Commercial_ Other <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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �p <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 Property Line <br /> SEEPAGE PITS ❑ Depth Size Number 1+ <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ` <br /> 1 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 p <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 California." <br /> The applicant ust call for all required inspections. Complete dr ing on reverse side. <br /> Signed <br /> itl <br /> a r e: Date: <br /> FOR DEPA MENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by <br /> Date — Final Inspection by r Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE tfAMO7UNTE AMOUNtREMITTEIDj) <br /> CASHRECEIVED BY DATE PERMITN0. <br /> INFO 7 Z+ EH 13.24 1REV.I B5) Jo � ` /.�� � � `—N-3to NO 7 <br /> EH 1428 <br />