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APPLICATION FOR PERMIT AY VA ED <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT RG�1V <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �319a <br /> Telephone (209) 466-6781 NQV <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ��7p,� <br /> (Complete in Triplicate) <br /> �NV�R��M�SEL�vlC�S <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 /> Job Address I� �] City 4 Lot Size PM <br /> 17 /Owner's Name )Ind, Address �� Phone <br /> ContractorW9QdA _Address da 4& License No. Phoneme-� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE- <br /> FOUNDATION <br /> INE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 0 Manteca Dia. of Welt Excavation Dia. of Well Casing <br /> IV Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern dace Seal installed by <br /> Repair Work Done A Type of Pump _A44f H.P. Z A, State Work Done � - <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50,/.,3,2;&, <br /> Depth f=iller Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Cl,,-'REPAIR/ADDITION LJ DESTRUCTION L7 (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ation will serve: Residence_ Commercial_ Other <br /> Number o units: Number of bedrooms <br /> Character of soil to a of 3 feet: s i, +- Water table depth <br /> SEPTIC TANK ❑ Type j Capacity'-" No. Compartments i <br /> PKG. TREATMENT PLT, ❑ j <br /> 6 f Method of Disposal <br /> Distance to nearest: Well ndation Property Line <br /> LEACHING LINE ❑ No. & Length of lines, - j r Toh/size <br /> FILTER BED E1Distance to nearest: Well Foundation Prop,r` ine <br /> M1t, 1 t <br /> SEEPAGE PITS ❑ Depth Size r Number - <br /> SUMPS ❑ Distance to nearest:-Im ..Well, Foundation ` Property Line -- - <br /> 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 /> rules and regulations of the San Joaquin Local Health District. c. I <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 workmari B-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." <br /> The applicant must ca r all required inspections. Complete drawing onverse'side. <br /> Signed / Title: Date: <br /> ~{ FO EPARTMENT USE ONLY <br /> i� <br /> Application Accepted by Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Data <br /> Additional Comments: <br /> L7 Stk 466-6781 r ❑ Lodi 369-3621' El Manteca 823-7104 ❑ Tracy .835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes*1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE F <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> + EH 13.24[REV.i/ar, )\ _ )\ VW. // <br /> EH 1428 (�°J (' L✓`—' /"�' <br /> r <br />