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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 Rules and Regulations of the San Joaquin <br /> Local Health District. .f <br /> F , <br /> r <br /> Job Address 7City Lot Size o&AX_ PM <br /> f <br /> Owner's Name Address Phare <br /> Contractors Name, License No. Phone /(� / a <br /> DESTRUCTIO <br /> TYPE OF WECL7PUMP:' NEW WELLtp a WELL REPLACEMENT ❑, N ❑ <br /> PUMP INSTALLATION ❑, , 1 SYSTEM REPAIR ❑+ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DfSPOSAL)—L" , PROP. LINE <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 Dia. of Well Casing <br /> ❑ Domestic/Private LI-Gravel-Pack-1— -- E7 Tracy Type of Casing E' Specifications-; <br /> ❑ Public ❑ Other ❑ Delta :Depth of Grout Seal ` 1 ` Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern 1Surface Seal Installed by s f 1�' <br /> r <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane <br /> Well Destruction Cl Well Diameter``L ° t `' Sealing Material Stop 50') 6 n <br /> Depth ~ �-'� �`` Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION V, DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> / �� available within 200 feet.) w <br /> Installation will serve: Residence_ Commercial_ Other i N <br /> Number of living units:—/—, Number,of_6edrooms. - -, .�_�.r- <br /> t <br /> Character of soil to a depth of 3 feet: WateP table depth <br /> SEPTIC TANK ❑ Type/Mfg ^Capacity No. Compartments <br /> / PKG. TREATMENT PLT. ❑ '``"Y Method of Disposal <br /> Distance to nearest. Well Foundatiori Property Line 1 <br /> Q <br /> LEACHING LINENo& Length of lines Total length/size Z a <br /> FILTER BED ❑ Distance to nearest: Well Foundation '-ld Property Line �f <br /> SEEPAGE PITS ❑ Depth Size_T�.... � Number. <br /> SUMPS fi ❑ Distance to nearest:- Well.l00 Foundation �f rtv Pro e. Line .f <br /> P <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:"`-"' 9 <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-b`ecome 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 pemilt'isissued,.1.shall employ persons subject to workman's compensa- <br /> tion laws of California." i€ <br /> The applicant must,call for VN requir sgectio . Complete drawing on reverse side. <br /> Signed Title: Q <br /> Oate: 00 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted b <br /> ,d Date � '�� Area <br /> Pit or Grout Inspecti Date Final Inspection b Date <br /> t <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 368-3621 Cl Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> :FEE AMOUNT DUE - `AMOUNT REMITTED CK•#` RECEIVED BY % ATE ER 'IN � Y <br /> INFO — CASH { DATE PERMIT NO. <br /> + EH 13-24 IREV.10/631 �S` O O <br /> EH 14-26 l 7�/�• %4_%<3 2 <br />