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I <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ! 1601 E. HAZEL T ON AVE., STOCKTON, CAi <br /> Telephone (209) 466-6781 fl$ <br /> P_�GvPERMIT EXPIRES 7 YEAR FROM DATE ISSUED ' ,-�, <br /> (Complete in Triplicate) D� ' <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'.aoo-licatiohTisj <br /> made in compliance with San Joaquin•County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and R&�ula ionsyof the Sof baquin <br /> Local Health District. r �� .. . <br /> 0/Job Address a City A to-Mi—ye PM <br /> Owner's Name _ `V �//Q�JCiC Jt//�Of1 d Address Phone <br /> Contractor t£ a Address�l� //� •�C- '— � License N � Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIRS OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES = 'QISP05AL FLD. PROP, LINE <br /> FOUNDATION -L} AGRICULTURE WELL `OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL ` -PROBLEM-AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca . Dia. of Well Excavation Dia. of Well Casing <br /> I <br /> XDomestic/Private ❑ Gravel Pack ❑ Tracy' Type of Casing Specifications <br /> (l Public f=1 Other Cl Delta . _ Depth of Grout Seal Type of Grout _ <br /> 'I I Irrigation I_Approx, Depth l I Eastern Surf ce Seal Installed by _ <br /> i <br /> :Repair Work Done Type of Pump H.P. 2 State Work Done4 <br /> ! -.Well Destruction ❑ Well Diameter Sealing Material.ltop 50T <br /> I. Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l I DESTRUCTION f I (No septic system permitted if public sewer is <br /> 3 available within 200 feet.) <br /> installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms <br /> r <br /> I'"Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity. No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> II <br /> r LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> • ...E U <br /> SEEPAGE PITS l I Depth "Size - Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property fine <br /> i 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. L I* <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 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> r <br /> The applica ust 11 for ail required ' ction ompl drawing on r side. <br /> Signed X o Title: / /Q —d I <br /> I i —` Date: , <br /> I FOR DEPARTMENT USE ONLY q ]� <br /> ,Application Accepted by / .� t ` Date t � Area Wil« l <br /> .I <br /> Pit or Grout Inspection by ate Final Inspection by Datew <br /> ..I <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 2008, SW., CA 95201 <br /> II , <br /> FEE <br /> I I INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'ND. <br /> 0 <br /> EH i4-2a <br /> +.EIH't3-24(REv.tiH5) <br /> % J <br /> iry <br />