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r <br /> Y <br /> ` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE I ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ` ­--PEAMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> tApplication 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 /> Local Health District. <br /> Job Address /`F" City a Lot Size / n <br /> Owner's Name f&Lqt�WW --�r�4sC Address / Phone Q C <br /> -Cont <br /> ractor`s Name q <br /> License No. Phone / l 4 t <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ElDESTRUCTION ❑ TV <br /> t PUMP INSTALLATION ®--' SYSTEM REPAIR ❑ OTHER ❑ <br /> r DISTANCE TO NEAREST: SEPTIC TANK 1_ArA2` +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 pen Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications o7 <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 :� H,P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 54'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> t available within 200 feet.) <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 LlType/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 11 No. & Length of lines Total length/size *: <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS El Depth Size ° Number <br /> SUMPS 1-1Distance to nearest: Well Foundation Property Line <br /> �� <br /> a �SPOSALPONDS ❑ <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 California." <br /> The applicant must call for all required inspections. Comple dr wing on reverse side. <br /> Signed <br /> i Title: Date <br /> xr <br /> d FOR DEPARTMENT USE ONLY <br /> Application Accepted by '-(Final <br /> Date+ Area <br /> "Pit or Grout Inspection by Date `(Final Inspection by / Date I?— <br /> Additional <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3627 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16D1 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> EH 13-24 H 14281REV.10f831 <br /> E (J Q I�� +� & <br />