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1, <br /> APPLICATION FOR PERMIT �td <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON CA •, <br /> Telephone (209) 466-6781 � ' 5 19 �~C\A <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> i Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work hd �t�Xl <br /> e in 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 Regus of the San Joaquin <br /> Local Health District. i <br /> b Address City Lot Size PINI <br /> caner s am Address o^ Phone <br /> Contracto Address d L`��0(�icense Phone `�/ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR .X OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. L__pROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA •CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial LJOpen Bottom - —C1 Ma meta, "r Dia. of Well Excavation Dia. of Well Casing <br /> XDomestic/private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I"1 Public 17) Other _n Delta-4 Depth of Grout Seal Type of Grout <br /> I I Irrigation _::Approx. Depth I 1 Eastern rface Seal Installed by ` <br /> It Repair Work Donei 1 <br /> Type of Pump _ H.P.— State Work Doneono r. _ <br /> Well Destruction top 5 <br /> ❑ Well Diameter Sealing Material-{ 0'1 V� <br /> Depth Filler'Material'iBelow 501 1 __ C>,► <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> "� 1' available within 200 feet.) d <br /> Installation will serve: Residence� Commercial_ Other <br /> Number of living units: Number-of bedrooms f <br /> +. <br /> °�Characier of sail to a depth of 3 feet: <br /> CWater table depth p <br /> SEPTIC TANK ❑ Type/Mfg Ca acit <br /> p Y N�. Compartments , ! <br /> PKG. TREATMENT PLT. ❑ �*•� �: Method of Disposal <br /> Distance to nearest: Well Foundation ___Proper1Y Line• 11 <br /> LEACHING LINE ❑ No. & Length of lines <br /> g Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl 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 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 the work for which this permit is issued, 1 shall employ pe <br /> tion laws of California." rsons subject to workman's compensa- <br /> The applican uw II for all req ired inspections. Complete drawing on verse side. <br /> a � , <br /> Signed,) <br /> Title: ,���� - Date: d <br /> FOR DEPARTMENT USE ONLY f + <br /> Application Accepted by '00� Date,�V Area <br /> Pit or Grout Ins <br /> pection by Date Final Inspection �^ 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 /> i FEE AMOUNT.DUE AMOUNT REMITTED CK . RECEIVED 8Y GATE PERMiT NO. <br /> INFO c� CASH <br /> +.EH14-241f1EV.i/w51 {� }��zs' <br /> EH 14-28 ✓ <br />