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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 TYEAR 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. 1962 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ash ``7 /"'� ,— City Lot Size PM <br /> Owner's Name �S Address '/ Phone <br /> Alrm 7=4_9 <br /> Contractor <br /> /it/�/US Address C icense No. �1e _Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION W eE�04> ,6T5TEM 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 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation —Approx. Depths�+��IyyI Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. 7— State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 LU dl <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION f 1 REPAIR/ADDITION i I DESTRUCTION { 1 -(No septic system permitted if public sewer is <br /> -available within 200 feet.] <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: Water table depth <br /> SEPTIC TANK 0' 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 i�o <br /> FILTER BED ❑: Distance to nearest: Well Foundation Property Line <br /> f <br /> SEEPAGE PITS I lz Deptti Size Number <br /> SUMPS ❑. Distance to nearest: Well Foundation Property.Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that l have prepared this application and that the work will be done in accordance with San Jo6g6in county ordinances, state laws, andO <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 II quired s. Complete drawing on97! <br /> Signed X� � Title: Dale: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by date Are <br /> Pit or Grout Inspection by Date Final Inspection b Date �� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant • Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED I CK RECEIVED BY DATE PERMiT'NO. <br /> INFO CASH / p <br /> + EH t4--28 IREV.t i N 51 S -1 S/ q/ $• 8`'Z <br />