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APPLICATION FOR PEFMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T Ofd AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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 well/pump and the Rules and Regulations of the San Joaquin II <br /> Local Health District. gSd?J2 <br /> 4 / `A <br /> 44her .54LC City Lot Size PM <br /> Job Address • <br /> II � <br /> Owner's Name <br /> r Address Phone <br /> I <br /> Contractor Uq"c'Iult COL J11110 Address Address - License No. Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR f OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _,797 DISPOSAL FLD. € PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS __ , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS it, <br /> 1-1 Industrial ❑ Open Bottom 1-1Manteca Dia. of Well Excavation Dia. of Well Casing <br /> t ' <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing ' Specifications <br /> f-1 Public ❑ Other C1 Delta Depth of Grout Sea{ Type of Grout — <br /> I I irrigation Approx.,Dept I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of PumOf H.P. — State Work Done t, . <br /> a <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 50') <br /> Depth <br /> Filler Material (below 501 — I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 'A EPAIR/ADDITION i I DESTRUCTION I l Mo septic system permitted if public sewer is <br /> """'""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:11 <br /> :' �r Water table depth ! n <br /> SEPTIC TANK ❑ Type/Mfg: Capacity =` `f No Compartments-,-- <br /> Method <br /> ompartments_fMethod of Disposal,' <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation, Property Line ri 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> .: <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> t Size Number <br /> SEEPAGE PITS I I Depth — _ <br /> SUMPS C1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared tfiis'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. 1 <br /> Home owner or licensed agent's signature certifies the following: '9 certify that in the performance of the work for which this permit is issued, I shall nooN <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 /> I! certifies the following: "1 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 /> i � <br /> I <br /> The applicant must call fo all requ' din%tio Cate drawing on reverse side. cy <br /> Signed X Title: Date: v f6 <br /> FOR DEPARTMENT USE ONLY t <br /> Application Accepted by Date 1—Ao Area 1 <br /> Pit yr Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: t <br /> ❑ Stk 466-6781 ❑ Lodi-.369.362l—(3 Ment666 823=7904""""p"❑`Tracy""835=6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stli CA 95201 <br /> FEE AMOUNT DUE 1 AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> . INFO <br /> ' SEH 13-241AEV.iiR51 ' <br /> � -1 t <br /> EH 14.26 V/0 -9 <br /> _ <br />