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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 /> 1 r (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. / d <br /> Q �0 x.� � ,! eJ! ,4 AlCity � f Lot Size PM # <br /> Job Address22A/— <br /> Owner's Name ice- Address �� Phone <br /> Contractor ,�t Address S��d /Pe44icense No. B Phone 4 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> a <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 ❑-Open Bottom- -❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ' _ T of CasingSpecifications <br /> 0 Domestic/Private ❑ Gravel Pack-A ❑ Tracy Type <br /> p Public E ❑ Others � ❑ Delta Depth of�Grout Seal Type of Grout r <br /> y d Irrigation �pprox- Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ,� Ty1 .pe of Pump ( H.P. I State Work Done <br /> '1 Well Destruction:4, ❑ ±Well Diameter 1 Seali g Material [top 50'} <br /> 1{,_!Depth f Filler Material (Below 501 <br /> d TYPE OF SEPTIC WORK: NEW INSTALLATIONXw REPAIR/ADDITION':❑'*DESTRUCTION ❑ (No septic system permitted if:public sewer is <br /> tt available within 200 feet.) <br /> Installation will serve: Residence 1 ECommercial— Other. <br /> Number of living units: Z Number of bedroomsl <br /> r # . - a Water table depth <br /> Character of soil to a depth of 3 feet: - <br /> SEPTIC TANK .2--Type Mfg, Capacity—� /No. Compartments <br /> ? PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> i <br /> 71.4-0 <br /> Distance-,to nearest: Well Foundation f Property Line <br /> 41 <br /> + LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> PILFER BED Ll Distance to nearest: Well -----.'"Foundation Property Line <br /> SEEPAGE PITS} ❑ Depth Size j Number } <br /> SUMPS ❑ Distance to nearest: Well Foundation .K Property Line <br /> DISPOSAL PONDS ❑ -�, <br /> i )thereby certify that I have prepared this application and that` rk the wow'iil'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 <br /> istrict:`- <br /> k 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 pers%on 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,1 shall employ persons subject to workman's compensa- <br /> t tion laws of California.",-- <br /> i T.he a icant mus II for all r spections. Complete drawing on neves side. - l <br /> R Y �! A <br /> Signed itle: _�! Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date*df Area ®- <br /> Date <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Additional Comments: <br /> • P <br /> E3Stk 466-6781 11Lodi 369-3621 ❑'Manteca-623-7104 ❑ Tracy 835 fi385 <br /> Applicant- Return all copies to: Environmental Health_Permit/Services_1601,E. Hazelton.Ave.,'P.O._Box.2009,-Stk.,-CA.95201-�-T <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO ; AOro <br /> '4 + EH 13-24IREV.1/a5) ✓/ V <br /> . EH W26 ddd 0/ + <br />