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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT p <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA W11E k �cII1vG • <br /> Telephone (209) 466-6781 --WAO 0l At/, ON 17-A'? ;. <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ]T19e-`T--qV-- <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. 1862 for well/pump and the Rules and Regulations of the San Joaquin , <br /> Local Health District. <br /> Job Address City—` '/s - Lot Size PM <br /> e <br /> �} Address ©° U - Phone <br /> Owner's Name lr�l7�- <br /> Contractor Address /C�License No. $I Phone Z <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 _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA" . CONSTRUCTION SPECIFICATIONS <br /> El Industrial C1 Open_Bottom ❑ Manteca ' {Dia. of Well Excavation Dia. of Well Casing <br /> © Domestic/Private ❑ Gravel Pack ❑ Tracy ;Type of Casing Specifications <br /> ❑ Public ❑ Other Cl Delta :Depth of Grout Seal Type of Grout <br /> I I irrigation --Approx. Depth l I Eastern Aurface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. ' State Work Doneiq QW61DWAI 46P,4 R;6-le <br /> Well Destruction El Well Diameter Sealing Material (top 50'i GO.Je'1X.� ���€' <br /> Depth T_ Filler Mategial (Below 501 — �d <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I i REPAIR/ADDI-66N l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> 'Installation will serve: Residence— Commercial_ Other ,' 3 <br /> Number of-living units: Number of bedrooms ; <br /> Character of soil to a depth of 3 feet: Water table depth (- <br /> SEPTIC TANK ❑ Type/Mfg Capacity:a } No..Compartments <br /> PKG. TREATMENT PLT, p 4 {. Method of Disposal <br /> Distance to' nearest: Well Foundation Property.Line r { <br /> LLL <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest. Well Foundation < Property Line r. <br /> SEEPAGE PITS l I Depth Size K Number._ - <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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."i 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 personssubject to workman's compensa- <br /> tion laws of California." <br /> The applicantr I requir s e tions. Complete drawing on reverses' e. <br /> d i <br /> Si ned X >s Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ` Date Area <br /> Pit or Grout Inspection by� Date Final Inspection by.)` Date <br /> Additional Comments: �l d — If <br /> j <br /> ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca a23-7104- ❑ 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 CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> +.EH t3-24 IREV.t i ss 51 <R , Z) tn <br /> EH 14-26 <br />