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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT L <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 /> v 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 r ;, <br /> Local Health District. 4 <br /> t <br /> Job Address 522 �b a <br /> Cit d Lot Size PM <br /> �} <br /> Owner's Na N 1. CS(� Address -3 € <br /> Phone ` <br /> Contractor '^ Addresst <br /> License No. Phone <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 i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavationi <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> ----Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 �1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIO REPAIR/ADDITION ❑ DESTRUCTIO (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 KType/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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line - <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll f <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. 4 <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of ifie 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" ust call for alquired inspections. Complete drawing on reverse side. <br /> c <br /> Sign d k' Title: Date:_�� .— <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by DateArse <br /> Pit or Grout Inspection Date- Final Inspection by Dat �Z-1 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L 1 ❑ Manteca 823-7104 ❑ Tracy 835-6385' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO CK RECEIVED BY PATE PERMIT'NO. <br /> + EH13-2AlREV.t/e5Y 2�"/ ��e0(.� 1©9� 1 .F !] `'�} <br /> EH 1428 �3L7 ! J,� 1C. � �� V ` <br />