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I <br /> 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)_11� > : t p <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 Or nce No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Loc <br /> �al ea th Di tric��3l�� �, Ja <br /> Job Address ( � City Lot Size PM <br /> 1 <br /> Owner's Name /� ,rAL— ddress4y �/� !� �� � Phone <br /> i <br /> Contract ddress L ce e No. Pho _ <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ �Q <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ w <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS J <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I i 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 Filler Material Malow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION I I (No septic system permitted if public sewer is <br /> J`�� X available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Othe1C_ <br /> Number of living units: Number f bedrooms v <br /> Character of soil to a depth of 3 feet: �/m� Water table depth <br /> SEPTIC TANK ❑ Type/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 Sixe Number <br /> i <br /> SUMPS ❑ Distance to nearest: Well "Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 Dibtrict. <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 applicant must call for all require sff) .Competed win on reverse side. <br /> Signed X -tie: Date: 7V Ir �� � <br /> FOR DEPARTM T USE ONLY A r <br /> lication Accepted by <br /> Date �JJ o Area ! p <br /> Pit Grout Inspection by\) Date r Final Inspection ON IV\ 5�J Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant• Return all copies to; Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO 1 `�^� (vR ♦f CASH -]�(� �r7 r� `/�?�}.11..�, <br /> r-Eli 13-24IREV-I/A5f �1 t"f�vV � � ����� r �/ ( v "" • � <br /> t Ek 14-2e l <br />