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APPLICATION FOR PERMIT (Y <br /> SAN JOQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. AZEL T ON AVE., STOCKTON, CAy,� <br /> .Telephone (209) 466-6781 <br /> PERMIT EXPIRES T YEAR FROM DATE ISSUED <br /> III (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 Noir 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 414/4Te City t Size o v PM <br /> l y �Owner's Name � f�ddress � �" � Phone <br /> I. <br /> Contractor,, ddress e License No. Fho/ 'n <br /> TYPE OF WELL/ UMP: & e NEW WELL ❑ WELL REPLA MENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEKI REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK iS�EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> WF <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial ❑ Open Bottom C] Manteca Dia. of Well Excavation pia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy('. Type of Casing Specifications <br /> ❑ Public ❑ Other L1 Delta�i Depth of Grout Seal Type of Grout--- <br /> I <br /> rout _I I Irrigation --Approx. Depth { I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter I Sealing Material (top 50 [ i <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is ^ i <br /> vailable within 200 teat.) lh�U <br /> Installation will serve: Residence_ Commercial i Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG, TREATMENT PLT. ❑ Method of Disposal <br /> i <br /> ti <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 0 No. & Length of lines Total length/size i <br /> FILTER BED ❑ Distance to neatest: We111 Foundation Property tine <br /> SEEPAGE PITS t I Depth -Size Number <br /> 1 <br /> SUMPS Cl Distance to nearest: Wel Foundation 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 s <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 toworkman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the followin : "I Certify at in the orm a of the work for which this permit is issued, I shall employ persons subject to workman's co pensa- <br /> tion laws of Califo <br /> The requir in ct' s. Complete drawing 7r verse side. <br /> If a 097CJX <br /> SignedOE <br /> l( Titl Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by I` Date ` Area ' <br /> Pit or Grout Inspection by Q Da�a Final Inspection by Date L <br /> Additional Comments: �J ,I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 Manteca 823 04 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services j16�01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> 1 <br /> �� lJt-Y f{. � ,�� �O fes_"� �-�_1.� ��t-f—'� 1✓� I <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> +.EH 13-24/REV.t i x 57J� 'IS 14-211 � �I�hi I � � �-Z5 <br /> �i � <br />