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APPLICATION FOR PERMIT I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <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 compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> I O <br /> Job Address L City Lot Size PM <br /> Owner's Name Wt FLO_�fln,Address Phone <br /> i I L2L A P& I <br /> Contractor AAddress License No. Q%S76L Phone <br /> TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT In DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR )I( OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS 9 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack - ❑ Tracy Type of Casing Specifications <br /> I`t Public' ❑ Other i7 Delta `Depth of Grout Seal Type of Grout_ _ <br /> I I irrigation _ ­—._Approx. Depth ! I Eastern Surface Seal Installed by <br /> Repair Work Done _❑ Type of Pump% TU H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') -. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I 'DESTRUCTION I 1 {No septic system permitted if public sewer,isi <br /> t available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other "Y <br /> Number of living units: Number of bedrooms { <br /> Character of soil to a depth of 3 feet: —Water table depth f <br /> SEPTIC TANK ❑ Type/Mfg Capacity jNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ,-LEACHING LINE ❑ No. & Length of lines l Total length/size µ \ <br /> FILTER BED ❑ Distance to nearest: Well Foundation( Property Line <br /> SEEPAGE PITS i I Depth Size f Number p <br /> F SUMPS ❑ 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 /> I Home owner or i• -sed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shah not <br /> employ any pe on n such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the fof?w' g: "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 rnia." <br /> The applMa_n ,stcall for all re ui d inspe ns. Complete drawing'on rev r side. <br /> Signed X Title: Date: <br /> OR OEPA T USE ONLY <br /> Application Accepted by Date Area <br /> 1 <br /> Pit or Grout Inspection byy Date Final Inspection by ` Date <br /> Additional Comments: <br /> ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-71041 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 4601_E.-,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> +-EH 13-24{gEV. M <br /> EH 14-28 �# �a..✓ (Q! / <br />