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u`Ln APPLICATION-FOR PERMIT <br /> 1,6-C, SAN JOAQUIN_LOCAL HEALTH DISTRICT f <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED , <br /> (Complete in Triplicate) . ?, <br /> F <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 <br /> Local Health District. , <br /> L.� r <br /> Job Addressr City .Lot Size PM <br /> Owner's Name On <br /> Address OW <br /> "yCeAUIS Phone I <br /> r ' <br /> Contractor's Name ` License No. J r ! Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ o <br /> PUMP INSTALLATION SYSTEM REPAIR )< OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK IV& SEWER LINES DISPOSAL FLD. PROP. LINE 111 tt <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 h <br /> 'i Domestic/Private ❑ Gravel Pack . ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth .,0 Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter tl Sealing Material (top 541 r <br /> _Depth-=_--1'N - Filler-Material•IBelow 50'1—•--- - <br /> •TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 011DESTRUCTIQN q ;(No septic system_permitted if public sewer is <br /> -"available'within-200feet.) '"""'" ." <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; s Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments k <br /> PKG. TREATMENT PLT. ❑ �' ; Method of Disposal <br /> f Distance to;nearest: Well 'Foundation Property Line <br /> [I <br /> `LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well !yti Foundation Property Line <br /> SEEPAGE PITS ❑ Depth r Size Number <br /> `SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑._ - <br /> t 1 lbreby 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 /> rtion laws of California." <br /> t <br /> EThe:applicant ust ca for all r uir in ctions. Complete drawing on revs a side. <br /> Signed Title: I«/' Ns, Date: O r� <br /> F DEPARTMENT USE ONLY �� ) <br /> Application Accepted by DateArea <br /> Pit or Grout Inspection by Date F' al Inspection by cYa.&aA%M�6C Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 836-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> INFO FEE AMOUNT DUE , AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT"NO. ? <br /> + EH 1324(REV.10183) <br /> EH 14-26 <br /> 1 J <br />