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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ' } <br /> Job Address i' City Lot Size�� ` PM <br /> Owner's Name ,. G Address J C­7 "� �--t -�' Phone <br /> Cantracto Q��a Address .Q -7 License No a CC Phon <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. PROP: LINE <br /> x r FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE- TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �X— <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ INo septic system permitted if public sewer is A <br /> ✓ available within 200 feet.] <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of Brooms <br /> Character of soil to a depth of 3 feet: _ �"` � lam"`" —Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> it <br /> SEEPAGE PITS Depth 43 Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation !D Property Line <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. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work forwirhich 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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m s call for all vire inspections. Complete drawing on revers e. <br /> g, <br /> Title: ' Date: <br /> Signed �,. ._- <br /> FOR DEP RTMENT USE ONLY '1 <br /> Application Accepted by Date iy� 1Area 12— <br /> 10 <br /> r Grout Inspection by atey Final Inspection by; 3r// Date <br /> Oit - <br /> Additional Comments: <br /> ❑ Stk 456-6781 , ❑ Lodi 3699-3621 - x❑ Manteca. 823-7104 Ll Tracy 835-2385 <br /> Applicant- Return all copies to Environmental Neaith'Pefmif/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK `RECEIVED$Y DATE PERMIT'NO. <br /> INFO GASH <br /> + EH 13-24(REV.1/x5) <br /> EH 14-26 <br /> r <br /> ' r <br />