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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) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ' <br /> x „ (COmplete�'yi�n 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 well/pump and the Rwles and Regulations of the San Joaquin <br /> Local Healfh District. <br /> Job Address PM <br /> - ; City R-� Lot Size ' <br /> Owner's Name /1/Jf'' Address 2- - - Phone <br /> Contractor Address/! i/ ` s! _ <br /> f � License No.q6sa-26_-_Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION 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 /> its Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other`; ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by V <br /> Repair Work Done K Type of Pump ��v H.P. I - State Work Done <br /> Well Destruction El Well Diameter .. - + <br /> Sealing Material [top 50')�-•- ` <br /> Depth s Filler Material (Below 501 � 13 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ {No septic system permitted if public sewer is W <br /> .available within 200 feeth t 7 <br /> i= <br /> Installation will serve: Residence_ Commercial Other <br /> �3 <br /> Number of living units: Number of bedrooms p " <br /> Character of oil to a depth'of 3 e-ef:""" <br /> Water table depth <br /> SEPTIC TANK ❑ Type/Mfg , l' <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. C7 `•' ' a " i <br /> Method of Disposal <br /> ADistance to nearest: Well Foundation Property Line I _ r <br /> it <br /> LEACHING LINE ❑t� :No. &;Length of lines Total length/size <br /> FILTER BED ❑ .Distance to nearest: Well Foundation Property Line 1' <br /> SEEPAGE PITS C7 Depth Size Number <br /> SUMPS P ❑ Distance to nearest: Well _Foundation Property Line <br /> DISPOSAL PONDS 171 ; <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-b t <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 /> 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 /> The applicant must call for I required inspections. Complete drawing on reverse side. <br /> Signed Title: - ` r <br /> Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by 41 �f� ' <br /> Date Area_ <br /> Pit or Grout Inspection by Date Final Inspection by 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 <br /> 1NF0 AMOUNT DUE AMOUNT REMITTED RECEIVED 8Y DATE PERMIT NO. <br /> +EH 13-24(AEV.I/as) /{ I� <br /> EH 1428 c� Q kf O^�Q <br />