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APPLICATION FOR'PERMIT <br /> i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {200) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> . iComplete 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:T s application is <br /> a 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. 't <br /> -;::�;..' 16`"•�r��i"�.#��:�#Fs'�41�:' '� y�£,,`'''�+ rt r�� _;-';� "J �,'f _ �u-�( <br /> Job Address { { *`� fiE! <br /> CC Lot Size PM <br /> Owner's Name­_-�"t Address <br /> I Phone <br /> ` Contractor AddressAlai—License No.C29Q a Phone Yom. <br /> F TYPE OF WELL/PUMP: U NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑. SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK wo"— SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS_ �M'�" � <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑Manteca Dia. of Well Excavation Dia. of Well Casing da <br /> Domestic/Private Gravel Pack ❑ Tracy Type of Casing °� Specifications <br />! ❑ Public ❑ Other f "❑ Delta Depth of Grout Seal T ~ <br /> ype of Grout �/� <br /> ❑ Irrigation �4ppro+. Depth ❑Eastern Surface Seal Installed by 4'�] <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane <br /> Well Destruction ❑ Well Diameter a Sealing Material {top 50'1 a � O <br /> ` Depth Filler Material (Below 50'1 �. <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 1 <br /> I available,within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number 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 /> r PKG. TREATMENT PLT ❑ E i Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ii <br /> LEACHING LINE C1 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> it <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line } <br /> DISPOSAL PONDS in <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 /> 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 applicant m st call for all require nspections. omplate drawing on reverses e. , <br /> SignedX-7" Title: Date: '712 5 <br /> '� FOR DEPA MEIVT USE ONLY , <br /> Application Accepted by Date <br /> Area AJ <br /> Pit or Grout Inspection by te. � Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy 835 6385 r <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> ?J <br /> INFO AMOUNT DUE I AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> g <br /> + EH13-24(REV. a51 i/ <br /> EH 14-28 __7 <br /> j <br /> i <br />