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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MAS 15 is <br /> (Complete in Triplicate) ENVIRONMENTAL HEALTH <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the wdrFPk44TAi 'h+Lsapplication is <br /> t made in compliance with San Joaquin C6unty Ordinance No. 549 for sewage or No. 1B62 for well/pump and the Rules and Regulations ol4a`�san Joaquin <br /> Local Health District. ,I <br /> } <br /> Job Address /-"-' !' � City Lot Size pM <br /> I � <br /> Owner's Name Address Phone <br /> Contractor <br /> Address /6 0� �`�' d r LicenseNo.4;� - Phone4- �- � <br /> TYPE OF WELL/PUMP: NEW WEL1—C ­ r I&,-tWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION 0 4 SYSTEM REPAIR 0 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE _- <br /> k FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> k INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> N,Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public {_1 Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> —.--- <br /> I I Irrigation —.-Approx. Depth l 1 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. 1�?r State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION ! I (No septic system permitted if public sewer is <br /> r available within 200 feet.) <br /> Installation will serve: Residence—' Commercial— Other <br /> Numbef 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 /> PKG. TREATMENT PLT. ❑ , Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total lengthFsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number - " <br /> SUMPS ��Jw_ Ll - Distance to nearest: _„Well 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 <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 /> j 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." I <br /> The applica ust �rallrequirgd�inspectio�ns �rawing on reverse side. tSigned' Title: Date:-j-9 / y <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 3 Area <br /> l <br /> t - <br /> Pit or Grout Inspection by Date Final Inspection by ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> I' Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> M FEE AMOUNT DUE AMOUNT REMITTED— CK '' RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +_EH 13-24(REV.tix51 3 Q9 0S <br /> EH 14-26 <br />