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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. 1 /� (� /� <br /> Job Address i e a Q 1 ! - H l/l�� l�+ O S { C j1 a <br /> y 1 — Cit!' s TICQot Size `-' V f Y PM <br /> V <br /> Owner's Name J 0 V v a �('(_ Address <br /> j�2 <br /> ^ A� //��_ (Phone <br /> Contractor (� Address Caa^ 3 7 �[� <br /> License Na. !'hone <br /> TYPE OF WELL/PUMP: NEW WELL K WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION iw"� SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFf <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excava rw,r <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Dia. of Well Ca 'ng <br /> V Type of Casing Specifications <br /> ❑ Public ❑ Other <br /> ❑ Irrigation ❑ Delta <br /> Depth of Grout Seal Type of Grout �- <br /> —Approx. Depth Eastern S fSeal Installed by rY' <br /> Repair Work Done Elce Type of Pump � H.P. iA/� I <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 G <br /> Depth Filler Material (Below SO') �- <br />'�— TYPE.OF-SEPTIC.WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION Li (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) { <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth , <br /> CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property <br /> LEACHING LINE ❑ No. & Length of lines Total length/siEe� + <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Proper <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in he 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 applican s call f r all d in do let drawingon r v side. <br /> Signed <br /> Title: �2 +� <br /> Date: <br /> ?_ <br /> FOR DEPARTMENT USE ONLY r <br /> Application Accepted by Date Y <br /> Area <br /> Pit or Grout Inspection by `Date Final 1`paction by hp 1� U <br /> y Date <br /> Additional Comments: <br /> ❑ Stk 456-6781 ❑ Lodi 1 ❑ Manteca 823-7104 ❑ Tracy 83546385 <br /> ^� Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95.201 <br /> ` FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> �\ INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> 1 <br /> + EH 13-241REV.t/a5) - _ S <br /> EH 1429 ���TTTT —` �77,--5k, <br />