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-fool- <br /> APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> j Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the Sari 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. <br /> Joh Address ""� City of Siz ' PM <br /> Owner's Nam <br /> U Address Phone ` <br /> ✓� /y. till/ .� <br /> Contractor r� pQ�Z4vAddress License No. Phone <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El �fJ <br /> PUMP INSTALLATION ❑ SYSTEM REPAI ,� OTHER ❑ E <br /> .DISTANCE TO NEAREST: SEPTIC TANK -��SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> l INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> EJ Industrial • ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. f Well Casing <br /> Domestic/Private F1 Gravel Pack ❑ Tracy Type of Casing Specifications L^ <br /> 1'1 Public f Other ❑ Delta Depth of Grout Seal Type of Grout - <br /> I 1 Irrigation Approx. Depth i I 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 I Filler Material (Below 501 <br /> t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:I REPAIR/ADDITION f I DESTRUCTION I I (No septic system permitted if public sewer is C..... <br /> f available within 200 feet.) <br /> i Installation will serve: Residence'r Commercial— Other <br /> 4 <br /> Number of living units: Number of bedrooms <br /> ' n <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ { Method of Disposal <br /> Distal to nearest: Well Foundation Property Line <br /> 11 <br /> LEACHING LINE ❑ No. &'Length of lines Total length/size <br /> FILTER BED . ElDistaht a to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 I Depthr Size _ Number <br /> SUMPS 0' Distanrce to nearest: Wel! Foundation Property Line <br /> DISPOSAL PONDS ❑ t <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 Di§trict. <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 t ark for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California ' <br /> The applicant must all for all required i ns. C pt a ing on reverse side. <br /> Signed X itle: <br /> Date: <br /> t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by �Z Date a� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 El Manteca 823-7104 0 Tracy 835-6385 <br /> Applicant - Return all capias to: Environmental Health Permit/Services 1601 E. Hazelton-Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> 24(REV.r r n sl ��. C ��/�� LXJ !(!✓ 2 <br />