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I <br /> i APPLICATION FOR PERMIT ' <br /> T <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p AG�1v�D <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA �ttE <br /> Telephone (209) 466-6781 <br /> il PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED R <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 <br /> ,"IA �V � <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulati an Joaquin <br /> Local Health District. ji •� <br /> if �'Size <br /> 9 �CI1a ( Lot PM <br /> Job Address _ City <br /> Owner's Name d �'r-' b * — Address �� Phone <br /> Contractor's Name ` f� <br /> Ho 'P� S'ense No �•i 2 Phone <br /> f TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ')e SYSTEM 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 /> a Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> T e of Grout e' 7 <br /> ❑ Public ❑ Other ❑ Deka Depth of Grout Seal yp <br /> I <br /> El Irrigation _„�4pprox. De��pth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump {�` <br /> b H.P. State Work Hone C&v ✓moi Illf- 01` op 4r <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic sy tem emitted if public sewer is <br /> avaa <br /> Installation will serve: Residence_ Commercial_ Other <br /> ” Number of living units: " Number of bedrooms <br /> Character of soil to a depth"Fif 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. El !? Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ii <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine <br /> U <br /> SEEPAGE PITS ❑ .Depth Size Number <br /> SUMPS ❑ FDistarice to nearest: Well Foundation ' Property Line <br /> DISPOSAL PONDS ❑ 1= <br /> 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 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 ap ant must call for all i �ctj . mplete drawing on reverse side. <br /> Signed <br /> ol Title: � �� Date: <br /> FO%DEPARTMENT USE ONLY <br /> Appl do Accepted by <br /> ! DateY a <br /> Date <br /> Pit or ut Inspection by F Date Final inspection by <br /> 4W, z <br /> Additional Comments: <br /> ❑ Stk 465-SMI El Lodi 389-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.r CA 95201 <br /> FEE AMOUNT DUE „ AMOUNT REMITTED C RECEIVED BYEDATE PERMIT"N0. <br /> INFO+ EH 13-24(REV.10163! ii! •� } �ZZ <br /> EH 14-26 <br />