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O� APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1� 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> " PERMIT EXPIRES�1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 21 —0710 OZ <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,weli/pump an the Rules and Regulations of the San Joaquin <br /> Local Health District. aoo~ r All <br /> Job Address r�R' �• �I(/ !�11�G City f Lot Size PM <br /> C (' <br /> Owners Name Address Phone �® <br /> i <br /> Contractor N001110.6fd Address License Nohone i <br /> TYPE OF.WELL4PUMP:l IQEW WELL 1-1 REPLACEMENT ❑ DESTRUCTION <br /> jW-PUMP.INSTALLATION ❑.� ..: SYSTEM REPAIR ❑ OTHER ❑ i <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE a <br /> FOUNDATION AGRICULTURE WELL OTHER WELL ' PITS/SUMPS Cy <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> p ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing s Specifications <br /> �t ❑ Pubfick ❑ Other ❑ Delta Depth of Grout Seal Type of Grout Tg <br /> n <br /> ❑ Irrigation r l ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> r <br /> 1} Well Destruction ' Well Diameter Sealing Material {top 6914' z <br /> Depth 4 ��` Filler Material {Below 501 <br /> TYPE OFSEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ElDESTRU ION ❑F IN septic system permitted if public sewer is <br /> . <br /> r 0 -available within 200 feet.) <br /> t <br /> Installation will'serve: Residence_ Commercial— Other <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 Capacity No. Compartments <br /> ii PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> f' LEACHING LINE' ❑ No. & Length of lines Total length/size <br /> l; a <br /> FILTER BED 1} 1 ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS.- ❑.,.,.Distance.to nearest:—Well ­•-----Foundation Property-Eine <br /> DISPOSAL PONDS El <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 /> I € rules and regulations of the San Joaquin <br /> i 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.',Contractors hiring or sub-contracting signature <br /> I —Zertifies the following:"I certify tfiat 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 /> !r' The applicant must ca or all requi d i e ns. Complete drawing on reverse ide. <br /> 1400, <br /> Signe rtle: aZ G � Dater � �� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by A Date — Area <br /> Pit or Grout Inspection by Date Final Inspection by.yAAeSA221 Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO . <br /> INFO CASH <br /> r <br /> + <br /> EH 1428 <br /> EH 13-24(REV.I R 5) <br /> �� <br />