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k - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. 3d & <br /> Job Address300 l L4 40b City Lot SizePM <br /> Owner's Name <br /> ' <br /> rTWAddress AJ. Phone ` "r <br /> ] <br /> Contractor's NamLicense-No. <br /> e+ `�10 Phone i <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 AGRICULTURE WELL OTHER.WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial -N Open Bottom - ;❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ <br /> Domestic/Private ❑ Gravel Pack �❑ Tracy Type of Casing ,. Specifications <br /> ❑ Public ❑ Other f ❑ Delta. Depth of Grout Seal ... ; Type of Grout <br /> ❑Irrigation --Approx: Depth ❑,Eastern Surface Seal Installed by I <br /> ' Repair Work`Done ❑ Type of Pump H.P. tale k DoAe <br /> Well Destruction Well Diameter Sealing Material atop 501 ; <br /> Depth " Filler Material {Below 50'! <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is G <br /> R available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> t <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 linesv Total length/size <br /> FILTER BED ❑ Distance tolnearest: Well Foundation Property Line <br /> � n <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation` Property Line n <br /> DISPOSAL PONDS ❑ 1 Z;; <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. <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 compensatioh laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I rtify t t in a perfor ante of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California. ' p <br /> The applicant 11 fired tion. Complete drawing on revers V�►J� <br /> I� Signed Title: U Date: <br /> E � <br /> FORT SE ONLY. <br /> Application Accepted by Date �+ a <br /> Pit or Grout Inspection by Date Final Inspection by� Dated <br /> .r• <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 95201 <br /> ` FEEAMOUNT DUE AMOUNT REMITTED K HT R_kEIVEO`BY DATE PERMIT'NO." : <br /> INFO CAS <br /> 9 �a <br /> • + EH 13-24(REV.10193) <br /> EH 14-26 U <br />