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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> to construct and/or install the work <br /> Application <br /> e n compliance witth Sanade othe n <br /> . Th'is application is <br /> Joaquin County Ordinance No.District Joaquin Local Health 549 for sewage or No. 1851 for well/pump and the Rules and herein <br /> Regulations of he San <br /> madcompliancwith Joaquin <br /> Local Health District. <br /> City ti Lot Size PM <br /> Job Address i <br /> M 4�P i ' Address N. Phone .. <br /> Owner's Name � . t <br /> Contractor's Name <br /> W j 1Icbfl! No. Phone 3 4- <br /> TYPE OF"WELL/PUMP: NEW WELWELL Ri PLACEMENT ❑ DESTRUCTION Q <br /> PUMP INSTALLATION-,15%. SYSTEM REPAIR'❑ i OTHER ❑ <br /> DISTANC, TO REST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD.� PROP. LINE <br /> d' UMPS <br /> FOUNDATION D AGRICULTURE WELL OTHER WELL PITS/S <br /> L .�' <br /> INTENDED USE 4 TYPE AOF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS A <br /> ❑ Industrial �' >Jp 71"n^tfttblfl'"" ---&X- 'eli x avatro+rr""'"" r . u v eu Lasmg <br /> �` Type of Casing- Specifications <br /> Domestic/Private ❑ Gravel Pack 171 Tracy yp g e <br /> ❑ PJ61ic' QOilier ❑ Delta Depth of Grout Seal �o Type of Grout <br /> ❑r Irrigation §�pProx. Depthv_ ❑w Eastern Surface Seal Installed by 00 <br /> Repair Work Done ❑ Type of Pump H.P.—� LL _ State Work Done <br /> Well Destruction ❑ Well Diameter f Sealing Material (top 561 ° <br /> f Depth Z/ Filler Material (Below 501 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION EJ DESTRUCTION El (No <br /> septilable c hne26D feeitted if public sew n is <br /> Installation will serve: Residence Commercial_ Other i <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..❑ 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 /> I � <br /> SEEPAGE PITS ❑ Depth Size <br /> r Number <br /> SUMPS 17 Distance to nearest: Well Foundation Property Line f <br /> DISPOSAL PONDS ❑ <br /> -I Hereby certif} that I have prepared this application and that the work will be done in accordance with San Joaquin coypty-ordinances, stateilaws, 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, 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 c IF or all re wired inspec ions. Complete drawing on reverse side. / S <br /> Signed X Title: Date: <br /> a <br /> FOR DEPARTMENT USE ONLY �y Q <br /> Application Accepted by - Date I "u�- Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: S' <br /> ❑ Stk 466-6781 Lodi 369-3621 El Manteca 823-7104 . ❑ Tracy 83�r6385 <br /> `. Applicant-- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2609, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO �$ 7 L <br /> $Q 7�o <br /> + EH 1}21 tREV 101831 <br /> `::.lEH L,428M1 <br />