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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> At1J <br /> ,A)Ox). �,(� 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> `PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein pPlication <br /> made in compliance with San Joaquin Codrmty Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and <br /> the San Joaquin <br /> Local Health District.. <br /> ((� City YQ Lot Size PM N <br /> Job Address <br /> 1 -- 9a <br /> Owner's Name Address r <br /> Phone O <br /> � <br /> (� Q r d icense No.� -Phone <br /> Contractor Address <br /> NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: SYSTEM REPAIR ❑ OTHER ❑ <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK _Zoo/ _ SEWER LINES <br /> DISPOSAL FLD.J� PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL- <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation , <br /> )I Domestic/Private <br /> Gravel Pack '% Tracy Type of Casing Specifications <br /> ElPublic ❑ Other {( Ll Delta Depth of Grout Seal _ 1A0� fo� T of Gro <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal installed by <br /> i' H P State Work Done <br /> Repair Work bone ❑ Type of Pump <br /> Well Destruction ❑ Well Diameter Sealing Material /top 50'1 <br /> Depth Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septilable with tem emitted if public sewer is <br /> Instailaf cin will serve: Residence�� Commercial_ Other <br /> Number of bedrooms <br /> Number of living uniWater table depth <br /> 3e <br /> Character of soil to a depth of fet- No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg °' Capacity <br /> Method of Disposal <br /> E <br /> PKG. TREATMENT PLT. ❑ �x� <br /> Distance to nearest: Well Foundation Property Line <br /> Tot 3l length/size <br /> LEACHING LINE ❑ No. & Length of lines Propaity--Une <br /> FILTER BED 1-1Distanceto nearest: WellFoundation <br /> I <br /> Number <br /> SEEPAGE PITS ❑ Depth + -Size "*4„ <br /> 1Foundation Property Line <br /> r SUMPS <br /> El Distance to nearest: Well <br /> f <br /> DISPOSAL PONDS ❑.,,. 1 -- - <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, an <br /> I <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."Contractors hiring or sub contracting signature <br /> I that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa <br /> certifies the fallowing: ' cern fY <br /> r tion laws of Califo ia." i E <br /> k The :Pplicnt mu t call for all requir spectians. mplete drawing e a side.Title: Date:Signd k <br /> FOR DEPA MENT USE ON L Date p <br /> rea <br /> Application Accepted by <br /> ` / A <br /> Pit or rout 1 spection by i <br /> Date Final Inspection by Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83585 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. BOX 2009, Stk., CA 95201 <br /> AMOUNT E AMOUNT REMITTED RECEIVED BY DATE "PERMIT'NO. <br /> FEE SH <br /> +I' INFO <br /> lF + EH 13-24(REV.1/5 5) `b( O 'A, <br /> EH 14-28 L V <br />