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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCACHEALTH 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 Ryles and Regulations of.the San Joaquin <br /> Local'Health District. -tet 'v.v.. �. <br /> f � -x •. <br /> lob'Address ' iffJ/ — j'[ I i �. <br /> ' j City G! '. Lot Size Z ACL _ PM <br /> Owner'\Nam �Z f _ '� . Address /6 3 :r A,' Phone <br /> Contract r Address 1J a`SC & License No.;�Phone 3 691— 1G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> t PUMP INSTALLATION ❑ SYSTEM. REPAIR ❑ OTHER ❑ <br /> DISTANCE-TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE `f <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE .TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; <br /> I ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing v <br /> LlDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public 3 ❑ Other , 1-1DeltaDepth of"Grout Seal Type of Grout <br /> 0 Irrigation Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 71 Well Diameter Sealing Material (top 50') <br /> ' Depth Filler Material (Below 509 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ EPA! ADDITION DESTRUCTION` mitted if public sewer is <br /> ❑�'(No-septic system per <br /> } t available within 200 feeft i <br /> Installation will serve: Residence Commercial Other <br /> Number of living units:--I,_ Number of room •A""' '' �� �-� i� <br /> Character of soil to a depth of 3 feet: / Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments 9 <br /> 'PKG. TREATMENT PLT. ❑ -' 1 r <br /> Method of Disposal <br /> Distance to nearest: Wel! --Fundatiori 4 Property Line O <br /> LEACHING LINE ❑ No. &+Keri fh of lines <br /> g f ?I _T <br /> ' otal length/size t r <br /> FILTFR`BED ❑ Distance to nearest: Well Foundation —.Prop6rty—.PropertyLine <br /> SEEPAGE PITS - W Depth s Size �J iiumber ! <br /> SUMPS ❑ Distance to nearest: Well Foundation Propertq Line <br /> h DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the'work will be done in accordance with d"'n Joaquin=county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. n: <br /> Home owner or licensed agent's signature certifies the following: <br /> "h certify that in the performance of the work for which thispermit 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'emplciy•persons'subject to workman's com ensa- <br /> tion laws of California." rE P <br /> The applicant at call for all uir inspections. Complete drawing on reverse <br /> Signed . ., r <br /> Title: Date: <br /> FOR`+DEPA TMENT US_E_ONLY 3 ' <br /> Application Accepted by <br /> Date• %` .`f� Area <br />' Pit r Grout Inspection by ate_. �! inal Inspection by ' Dat <br /> r Additional Comments: 4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 'C7 Tracy-'r65 6385 <br /> t 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 DATE PERMIT N0. <br /> INFO CASH <br /> t <br />