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APPLICATION.FOR.PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL—1 ON .AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 Y.s V_ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED yhocia-tcl t,.rf1 tr <br /> (Complete in Triplicate.) <br /> ork herein described:This application is <br /> Application is hereby made to the San JoaqLocal Health District for a permit to construct and/or install the w <br /> uin <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. = E ; <br /> CitAff-4ES-CALC of size . . PM <br /> Job Address �--- <br /> Owner's Name <br /> Phone <br /> +} <br /> Contractor's Name <br /> F1L License NO Phone', <br /> TYPE OF WELL/PUMP: NEW WELL C1 WELL REPLACEMENT ❑ DESTRUCTION El <br /> PUMP INSTALLATION 13 SYSTEM REPAIR ❑ OTHER ❑ 5 <br /> .DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP• LINE. A. <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Specifications <br /> ❑ Tracy Type of Casing <br /> VCDomestic/Private ❑ Gravel Pack <br /> Type of Grout <br /> El Public C3 Other Ll Delta Depth of Grout Seal y <br /> e <br /> ❑ Irrigation _J',pprox• Depth El Eastern Surface Seal Installed by <br /> � M H P �_ _ State Work Done <br /> Repair Work Done ❑ Type of Pump l�-F _ <br /> E Well Destruction ❑ Wel! Diameter Sealing Material (top 501 <br /> Depth Filler Material IBelow 501 <br /> ti< TYPE OF SEPTIC WORK: NEW INSTALLATION LJREPAIR/ADDITION ❑ DESTRUCTION ❑ avail blew thin 200 feet.)permitted if public sewer is W <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> - WaAD <br /> f <br /> i Character of soil to a depth of 3 feet:' No <br /> [# ❑ Type/Mf Capacity <br /> SEPTIC TANK g — Me1 <br /> PKG. TREATMENT PLT. ❑ Property <br /> Distance to nearest: Well Foundation <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> k FILTER BED .❑ Distance to nearest: Well <br /> Foundation Property <br /> Size Number. <br /> SEEPAGE PITS ❑ Depth ..Property <br /> SUMPS •❑ Distance to nearest: Well Foundation - <br /> f 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 /> the San Joaquin Local Health District: <br /> ignature certifies the following: "I certify that in the performance of the work for which this permit is i <br /> Home owner or licensed agent's sssued, I shall not <br /> rules and regulations of <br /> i' signature <br /> employ any person in such manner as to become subject to workman's compensation laws ss California."Contractor's <br /> t workman's sub-contracting ompensa <br /> certifies the following:"1 certify that in the performance of the work for which this permit is issued,I shall employ p® s <br /> tion laws of California." ' <br /> The applican ust Cali for all required inspections. Complete drawing on reverse side. <br /> Date: <br /> i Signed Title: <br /> ° FOR DEPARTMENT USE ONLY <br /> kDate V 7 C Area <br /> AA <br /> Application Accepted by - <br /> Date�� <br /> Final Inspection by <br /> Pit or Grout Inspection by bate <br /> Additional Comments: <br /> ❑ Stk 466-678'1 ❑ Lodi 3��621 ❑ Manteca 623-7104 ❑ Tracy B354M <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> F -. <br /> CK RECEIVED BY DATE PERMIT'NO. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> INFO <br /> g/'iaf -tiny) <br /> + EH 13-24(REV.101831 <br /> EH 14-28 <br />