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1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone {209} 466.6781 <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) 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 k <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. A <br /> r <br /> 6 �Job Address City of Size PM <br /> r <br /> Owner's Name Rdress 20 1 Mlz Phone <br /> Contractor P4 `1 Address License No. Phone <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ VSYSTEM 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 f CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1-1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth (.I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P.' State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') O <br /> Depth Filler Material iBelow 50'1 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION f I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_� Commercial_ Other <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 ' No. Compartments ` <br /> PKG. TREATMENT PLT. <br /> El <br /> of Disposal <br /> �1 Distance td 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 I 1 Depth I Size _ Number <br /> IV) SUMPS L-1 Distance to nearest: Well Foundation Property Line <br /> `;�3 DISPOSAL_ PONDS ❑ I 1 <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 /> X rules and regulations of the San Joaquin Local Health District. <br /> �V\ 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 y <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: " ertify 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 Californi k <br /> The applicant must II all re it d inspections. Complete drawing on reverse side. <br /> Signed X Title: — -� -z/� tate: <br /> " � FOR DEPARTMENT USE ONLY`- <br /> Application Accepted by Date c7 ll� C. Area <br /> Pit or Grout Inspection by Date Final Inspection by W Date <br /> t'�F <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 1-] 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 �Cc.✓whvrFy pr1zi) Uv'� <br /> - FEE <br /> INFOL07 AMOUNT DUE ,' AMOUNT REMITTED CAfiH RECEIVED BY DATE PERMIT-NO. <br /> + EH 1415L-324 51 ? 7187 7� �n40u-�` I,►�t, <br /> Ce p. Y17- --ccP, <br /> rk} _ <br />