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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ,1601 EMAZELiON"AVE., STOCKTON, CA <br /> Telephone p 12091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED. <br /> . �. (Complete in Triplicate) <br /> r <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 /> Local Health District. <br /> /T[ PM <br /> City rte <br /> Job Address _ — - <br /> o✓>� ` PlioneL <br /> Owner's Name � f T ��e', t Address <br /> Contra7 License No]. <br /> Phonector VJv%4_S e <br /> TYPE OF WELL/PUMP: NEW WELL F1WELL REPLACEMENT 11DESTRUCTION ❑ <br /> Y PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST:_ SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> ---INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing a <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> © Public ❑ Other ❑ Delta Depth of Grout Seal Ty of Grout j <br /> ❑ Irrigation ---Approx.;Depth ❑ Eastern urface Seal Installed by— <br /> Repair <br /> � i <br /> Repair Work Done W Type of Pump LA H.P. State Work <br /> / Done ✓ <br /> Well Destruction E Well Diameter Sealing Material (top 501 <br /> r. <br /> Depth 4 'Filler Material,,{Below 50'i i n <br /> TYPE OF SEPTIC WORK: NEW INSTALL'ATION,❑: REPAIR/ADDITION'❑' DESTRUCTION ❑ ,(No_septic,.cystem-permitted-if-pubffc-sewer is;y r I <br /> ,r�-�_ - --^ .-w a-•-.. .---_ available within 200 feet.) �r t S <br /> 1 installation will serve: Residence_ Commercial Other f 10 Y S <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: J s Watert`aale depth <br /> Capaci j�'• ' No:tgmpartmehts ?f"± <br /> SEPTIC TANK ElType/Mfg ty <br /> PKG. TREATMENT PLT. ❑ � ---^"'-'Method of-Disposer"' <br /> Distance to nearest: Well Foundation # Property fine <br /> i <br /> ' Total len th/size of { r <br /> LEACHING LINE ❑ No. & Length of lines 9 , <br /> FILTER BED ❑ Distance to nearest: Well Foundation �Property- Linea <br /> j 9 <br /> Pf J <br /> 4 SEEPAGE PITS 11 Depth Size Number Yr <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line „ <br /> x <br /> DISPOSAL PONDS ❑ f F <br /> 1 hereby certify that I ared this-application and that the work will be done in accordance with San Joaquin county ordinances, state laws;,arid <br /> rules and regulatia of the San oaquin Local Health District. <br /> Home owner or ' ensed agent's nature certifies the f Ilowing: "I certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any pe on in such manna s to become sub' t to work Go cation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the f awing:�'I certify t t in the rforma of e w f is this per <br /> is issued,I shall employ persons subject to workman's corrnpensa <br /> tion laws of- aiifornia." <br /> The applic ' t mustall qquired ' spa ro rawing reve s e. <br /> Signed r Date: <br /> R DEPARTMENT USE ONLY !�yy �; �+ j <br /> Application Accepted Date g-R-Or. Area <br /> { <br /> Pit or Grout Inspect y Date Final Inspection by Date � � <br /> . <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 .. ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O; Box 2009, Stk., CA 95201 <br /> r FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 6Y' DATE PERMIT'NO. <br /> I I <br /> + EH 1324IREV.7/e51 <br /> a EH 1428 <br />