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Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L1 �/ <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA L <br /> L/ Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED 2 <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the wor ere,.described. This app,cotton is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address a lI If 1 Cit <br /> # Y � Loi Size pM <br /> Owner's Name„ b t. Address �.Q�1��5 2. phone 3 eI <br /> ! ,l �.. <br /> Contractor Address +�Z Y Jt (� r� G { <br /> License No:l�'7��3�Phone a2` <br /> TYP—EO F WELLlPUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES f <br /> DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS i' <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it <br /> 1:1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Specifications <br /> Ff Public 1! 71 Other Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation --Approx. Depth l I 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 50') Q <br /> Depth Filler Material (Below 50') u) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION I 1 DESTRUCTION fNo septic system permitted if public sewer is <br /> ' f ' <br /> Installation will serve: Residence available within 200 feet.) <br /> .Commercial Other <br /> Number of livingunits: <br /> Number of bedrooms <br /> Character of soil to a depth of 3 feet:i t Water table depth a ' <br /> SEPTIC TANK TypelllAfg Capacit'--17— <br /> Y --Nii`Compartments— 0 i. <br /> PKG. TREATMENT PLT. <br /> � Method of Disposal <br /> Distance to nearest: Well. Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines , <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well Foundation <br /> ( Property Line <br /> SEEPAGE PITS <br /> 11 Depth Size � Number <br /> SUMPS i f ❑ Distance to nearest: Well Foundation property Line <br /> DISPOSAL PONDS f ❑ <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, tate 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 for which this permit is issued, I shall not I <br /> employ any person in uch 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 em Io p t <br /> tion laws of California." p Y Persons subject to workman's com ansa- ti <br /> The applicant ust II for all required inspections. Complete drawing on reverse side. <br /> Signed X t <br /> Title: ¢ . D 15 !f <br /> ate: -� <br /> FOR DEPARTMENT USE ONLY A' f <br /> Application Accepted by Date . / 3 <br /> rea <br /> Pit or Grout Inspection b Date Final Inspection b <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ odi 369-3621 © Man eca 823-7104 EI 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> CASH DATE PERMIT'NO. )' <br /> r EH 14-24(REV.t o 5) <br /> tr EH 14-26 - <br />