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1 <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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> ` t <br /> Owner's Name Address Phone I <br /> Contactor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION L7 <br /> s. - <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR_] `�`OTiiEA'❑ <br /> DISTANCE TO NEAREST SEPTIC TANK 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 /> Ll Industrial El Open Botmrri a Manteca Dia.o of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack. '— ❑ Tracy Type of.Casiiig Specifications <br /> * Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irtigation , — '.-Approx. Depth I Eastern Surfac&Seal Installed by - <br /> Work D <br /> Repair Work pone ❑ Type of Pump H. State Worone <br /> +-`- _ <br /> Well Destruction "01 Well Diameter - Sealing Material (top 501- <br /> 564 <br /> Depth �` Filler MaterialF(Belo`w — �✓1 i <br /> p V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION l 1 DESTRUCTION l I INo septic system permitted if public sewer is 1 <br /> ,/ available within'200 feet.i. m <br /> Installation will serve: Residence—L Commercial— that <br /> n :�4 $ <br /> Number of living units: A- Number of bedrooms <br /> Character of to.a depth of 3 feet: 1pa 46,2 KK.a Water table depth <br /> :. SEPTIC TANK ❑ Type/Mfg CapaciNo. ,Compartments <br /> PKG, TREATMENT PLT. ❑ ! a Method of Disposal ' <br /> i lJ <br /> % �..FrT <br /> Distance to nearest: Well �Foundation Property Line I t <br /> 7 ;'Sk"f EA HIlVG LINE Nor-.4 Length of lines — � Total length/size M FT <br /> rpt FILTER SED ❑ <br /> Distance to nearest: Well Foundation Property Lme,i, <br /> SEEPAGE PITS i I Depth �T Size — Number <br /> rDistance to nearest: Well Foundation Kb-e Property Line <br /> SUMPS _. <br /> I J DISPOSAL PONDS ❑ ! 1 <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. s Ei j <br /> Home owner or licensed agent's signature certifies the follovi ing: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> I employ any person in such manner as to become subject to workman's compensation laws of Cafifornia=-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 /> tionlaws of California." <br /> The'applicant must call for all_required inspections. Complete drawing on.reverse side. <br /> Signed X fJ Title: .. `f bate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Data �f Are 1"' <br /> Pit or Grout Inspection by Date Final inspection by 4,.JDate <br /> ` Additional Comments: y <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 1 <br /> Apphcarlt - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box,2W91 Stk., CA 95201 <br /> - —.--^ 'FEE i1MOt7NT`Dt7E —AIVIOUI 1r REMITTED CASH T RECEIVED BY _.. ' DATE PERMIT NO. <br /> INFO <br /> + EH 13.241REV.iin5) © 11 <br /> 6 ' EH 14-26 <br /> i ' <br />