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APPLICATION FOR PERMIT , ,. <br /> SAN JOAaU1N LOCAL HEALTH DISTRICT <br /> r <br /> 1601 .E. HAZE-LTON AVE., STOCKTON, CA c <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE'ISSUED ""'k ws°"�`' <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 /> ,. City Lot Size .. PM <br /> Job Address <br /> , <br /> Owner's Name Address Phone <br /> r � <br /> Contractor Address <br /> Az�41 Q License 3Agq,,,Phan <br /> I TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> 1 PUMP INSTALLATION CJ <br /> REPAIR ❑ OTHER ❑ <br /> i DISTANCE TO NEAREST. SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION—__ `'AGRICULYUAL WELL OTHER WELL` PITS/SUMPS. _ <br /> t: - <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> E] Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. f Well Casing <br /> l ElDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> fl <br /> El Public 11 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 171 Irrigation �pprax. Depth ❑ Eastern Surface*Seal Installed by 1 'A <br /> Repair Work Done ❑ Type of Pump H.P. '' t ' State Work Dane <br /> Well Destruction LJ Well Diameter Sealing Material {top'650'Y ` <br /> 1r► Depth """"`"'Filler,Material-fBelow50'1 ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRIADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> i .1 �yailable 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: I Water table depth <br /> r No.`Compartments <br /> SEPTIC TANK ❑ Type/Mfg i Capacity-- "-" ,� i, <br /> 1 PKG. TREATMENT PLT. ❑ i!! .1 Method of Disposal <br /> Distance to nearest: Well Foundation. Property tine <br /> _ a <br /> LEACHING LINE 1-1No. &ILength of lines l Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Prdperty Line <br /> L <br /> SEEPAGE PITS ❑ Depth) Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 or1icensed 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'iri the performance of the work far.which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of Cal' rnia." <br /> ` The applicant t call for all required ' p ions. plate drawing onyre rse r <br /> /ter � - Rate: <br /> �® <br /> Signed Title: <br /> ' FOR DEPARTMENT USE ONLY <br /> b <br /> Applicafi Accepted by Date Area <br /> Pit or Grout Inspection y Date Final Inspection by Date 2� <br /> Additional Comments: <br /> ❑ Stk 466-6791 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 1324(REV.1/e 5) �^ 43"� _ - 1-1�'47 / <br /> EH 44-28 ���•••JJJ .- <br />