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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 601 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 1 <br /> made in compliance with San Joaquin County Orc inance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District., J <br /> Job Address Y <br /> City fV Lot Size�� gCpM <br /> Owner Is Name` I [/ Address J '� �Q�j <br /> Phone 9 <br /> Contractor � � " � l.C,o�J� 1 o <br /> Ad cess I /41 1� _License,No <br /> TYPE OF WELL/PUMP: Phone <br /> NEW WEL ❑ WELL REPLACEMENT ❑ jDESTHM,TION f� <br /> PUMP INSTALLATIO El SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES r <br /> DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> PITS/SUMPS <br /> INTENDED USE TYPE OF WELL . PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑'Open Bottom ❑ Manteca Dia. of Well Excavation <br /> El Domestic/Private ❑ Gravel PackDia. of Well Casing <br /> ❑ Tracy Type of Casing <br /> fSpecifications <br /> F1 Public C7 Other I:t Delta Depth�of Grout Seal <br /> I f Irrigation Type of Grout <br /> --Approx. Depth I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. <br /> 5 to Work Done_ <br /> Well Destruction Well Diameter Sealing Material trop 50') r <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.] REPAIR/ADDITION ! I DESTRUCTION I I (No septic system permitted if public sewer is <br /> Installation will serve: Residence Commercial i Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK. ❑ Water table depth <br /> PKG. TREATMENT PLT. <br /> r Type/Mfg Capacity No. Compartments <br /> Distance to nearest: Well <br /> Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of fine <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I'} Depth Size _ t <br /> ` Number <br /> SUMPS Ll Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> f <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 law <br /> rules and regulations of the San Joaquin Local Health Di'strict. s, and <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 su iect to workman's compensation laws of California."Contractor's hiring or sub-contracting signature f <br /> certifies the following: "I certify that in the performar ce 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 m s't�for all required inspections. Complete d ing,on vers�e'side. <br /> Signed X Title: <br /> Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by _._. Date <br /> Area <br /> Pit or Grout Inspection br, <br /> r� 'Data Fi al Ins 001 by , 9 <br /> Date <br /> Additional Comments: .-- <br /> ❑ Stk 466-6781 El Lodi 1 ❑ Pillanteca 823-7104 V ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Heal Permit/Services 1601 E. Hazelion Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE"— —A-k-O NT'REWIITTED'r CASH _ RECEIVED BYE DATE <br /> PERMIT NO. <br /> +.EH 13-24 1AEV.I/H 5} �r <br /> EH 74-26 <br />