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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 /> 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 1 -76 <br /> 1/ City Lot Size p PM <br /> Owner's Name V �:���!'T7� Address �"e— <br /> Phone <br /> )4:- <br /> Contractor P' Address' License No. Phone <br /> TYPE OF WELL/PUMP•: NEW WELL ❑ WELL REP CEME=NT ❑ DESTRUCTION ❑ <br /> #' PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F' ❑ Industrial ❑ - — --------- t . <br /> 0 n Bottom r <br /> Pe ❑ Manteca Dia. of Well Excavation Dia, of Well Casing <br /> y t ❑ Domestic/Private ❑ Gravel Pack y ❑ Tracy 'Type of Casing Specifications <br /> ❑ Public Q Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. D th Eastern / urface Seal Installed by <br /> Repair Work Done ❑ Type of Pum H.P. _ _ State Work DoneI* -- <br /> Installation <br /> I <br /> Well Destruction . ❑ Well Diameter Sealing Material (top 50') ! <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic p system permitted if pavailable within 200 feet.l 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 /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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." , , <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X� W <br /> — le — <br /> fZ �_ Tide: Date: <br /> FOR DEPA TMENT USE ONLY <br /> i <br /> Application Accepted by - Date " Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> .Additional Comments:,, <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA SU01 <br /> FEE AMOUNT DUE AMOUNTREMITT <br /> INFO ED RECEIVED BY DATE PERMIT''N0. <br /> + E11429 ��3-20fREV.t/951 <br /> EHR � '�� _ - � wt l( � `1-O �` ,�� � <br />