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APPLICATION FOR PERMIT rr� <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM r,ATE 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 . Cit <br /> Y ' rr-.Lot Size PM <br /> Owner's Name f <br /> -- -- I– Phone ±tir i 2 <br /> &� ddress -r`` �`1 1 f ` <br /> .r.. License No. '�; Ei Phone cj � �I, <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. POOP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS" <br /> ❑ Industrial ❑ Open Bottom "C7 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> C] Domestic/Private ❑ Gravel Pack ❑ Tracy Type of CasingSpecifications <br /> M Public t n Other i n Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Inigaricn —Approx. Depth I I Eastern Surface Seal Installed byr. <br /> Repair Work Done 1�1 Type of Pump 0.P. St-pte Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') , <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRlADDITtON t I DESTRUCTION No septic system permitted if public sewer is <br /> available within 200 feet.) ` <br /> Installation will serve: Residence_ Commercial_ Other n, <br /> Number of living units: Number,of bedrooms <br /> Character of soil to a depth of 3 feet; Water table depth <br /> SEPTIC TANK ❑ Type/Mfg I Capacity No. Compartments r,+` <br /> PKG. TREATMENT PLT. ❑ <br /> i Method,of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Weil Foundation <br /> Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS I_i Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <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 shalt employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X !' j _ f%' 'J• '�f f <br /> Title: _ % <br /> �. Date- <br /> FO1g04,R1rMENT USE ONLY <br /> Application Accepted by , •. Date ..{f%A! <br /> Area <br /> Pit or Grout Inspection by <br /> Data Final Inspection by <br /> Additional Comments: l r + <br /> _ Date <br /> rr . <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 p 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 /> FEEOUNT DUE AMOUNT REMITTED K <br /> INFO CASH RECEIVED BY DATE PERMIT*NO. ' <br /> EH142AffiEV.iiesr �� ^0 ,� "•r� y / <br />