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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"I YEAR FROM DATE ISSUED <br /> .w.{ t - <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 <br /> compliance with San Joaquin County Ordinance No:549 for sewage or No. 1562 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health'District.'' <br /> Job Address Q / ! f~ Y <br /> �` City � � Lot Size PM <br /> .,, <br /> Owner's Name <br /> Address <br /> Phone <br /> Contractor 7 Address 1 <br /> TYPE OF WELL/PUMP: License No. O Phone <br /> I W WEL�'o - � WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C1 ".SYSTEM REPAIR'❑, <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> _ SEWER LINES. _DISPOSAL FLD. _ _P.RO.P...LINE <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELL PITS/SUMPS <br /> INTENDED OSE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial` ' ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 1-1Domestic/Private EJGravel Pack El Tracy T Dia. of Well Casing j <br /> ❑ Public pt of Casing Specifications 1 <br /> ❑ Other L2 Delta Depth of Grout Seal <br /> ❑ irrigation ---Approx. Depth _❑_Eastern Type of Grout <br /> Repair Work Done ❑ Type of PumSua��eal-lnstsFled by , <br /> � p H.P.SealiState Work Done <br /> Well Destruction ❑ Well Diameter f r <br /> Sealing Material (top 50'1 € ,. <br /> Depth Filler Material {Below 50'1 1 w <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION L7 REPAiR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted'if public sever is a <br /> Installation will serve: Rsidence_ Commercial available within 200 feet.) <br /> Other - <br /> Number of livingunits: A <br /> Number of bedrooms <br /> Character of soil to adepih of 3 feet: F i <br /> r <br /> SEPTIC TANK ❑ Type/Mfg j Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity f I No. Compartments j <br /> F : <br /> 1 Method of Disposal <br /> Distance to nearest: Well <br /> y Foundation 'PropertyLine t <br /> . <br /> LEACHING LINE ❑ No. & Length of fines i G <br /> FILTER BEDToial length/size 4 <br /> _ ❑t Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS Depth <br /> lid Size t <br /> SUMPS Number, ❑1 Distance to nearest: �-Well <br /> DISPOSAL PONDS ❑ .- Foundation <br /> —1L2� Property Line <br /> I hereby certify that i have prepared this application and that the work will be done in accordance with San Jordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. oa quin county <br /> Home owner or licensed agent's signature certifies the following: i <br /> employ an g "I certify that in the performance of theiTi+ork fol which this permit is issued, i shall not <br /> P Y e person in such manner as to become subject to workman's_compensation laws.of-ince of <br /> Go rk'f o�s hiring or sub-contracting signature <br /> certifies the following: "I certify[hat in the performance of tof the work for which this permit is issued, 1•9hal!employ <br /> tion laws of California." { p y persons subject to workman's compensa- <br /> The applicant usi all fo all ins tions. C ��wing�on reverse side. <br /> Signed X <br /> , �"*� ,� Date: 1. <br /> FOR DEPARTM—ENT USE ONLY,= � -.— <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout inspection by Date <br /> Area Inspection by Date <br /> Additional Comments: I <br /> A Stk 466-6781 L1 Lodi 369-3621 LJ Manteca Manteca 823-7104 - 8356385 r <br /> pp rcant Return all copies to: Environmental Health Permit/Services,1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE EN 13-24 AMOUNT DUE' AMOUNT REMITTED <br /> INFO JCASH RECEIVED BY DATE <br /> PERMIT NO. <br /> 4 EH 1428(REV.tirisl �` 1. . <br /> 40� <br />