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APPLICATION FOR PERMIT P <br />SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br />1601 E. HAZELON ON AVE., STOCKTON, CA Wa� <br />Telephone 12091 466-6781 No 61L J._J, Ird <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />_z���. <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. THs 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 />14r 7/1 Z' 'AL IT% r:... /11 —77AV --A I ..r Cion PM <br />JOB AOUreSS r v.. i - w <br />..�.r• - - - �......�.. - -- <br />Owner's Name Address <br />f Phone .6 <br />Contractor's Name License No. <br />Phone <br />TYPE OF WELL/PUMP:_ NEW WELL,4 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />PUMP INSTALLATION X <br />SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK ZV0 f SEWER LINES <br />_— DISPOSAL FLD. 14 1) PROP. LINE <br />FOUNDATION --5— AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE TYPE OF WELL PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />❑ Industrial ❑ Open Bottom Manteca <br />Dia. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private Gravel Pack ❑ racy <br />•❑ <br />Type of Casing "! Specifications <br />❑ Public ther ❑Delta <br />Depth of Grout Seal .'S(7 Type of Grout% <br />❑ Irrigation /2._—Approx. Depth ❑ Eastern <br />Seal Installed by <br />Repair Work Done )< Type of Pump H.P. <br />Zrface <br />State Work Done <br />Well Destruction ElWell Diameter Sealing Material (top 501 <br />Depth Filler Material (Below 50') <br />TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br />available within 200 feet.l <br />Installation will serve: Residence — Commercial -7e Other <br />Y <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />Water table depth <br />SEPTIC TANK ❑ Type/Mfg <br />Capacity No. Compartments <br />PKG. TREATMENT PLT. ❑ <br />"" Method of Disposal <br />j Distance to nearest:` Well <br />Foundation Property Line <br />f <br />LEACHING LINE ❑ No. & Length of lines - <br />/ Total length/size <br />FILTER BED k ❑ Distance to nearest: Well <br />Foundation Property Line <br />SEEPAGE PITS ❑ Depth Size <br />Y ` ' Number <br />SUMPS ❑ Distance to nearest: Well <br />Foundation Property Line <br />DISPOSAL PONDS ❑ <br />r I <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 District. i r <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 required 3!Weciions.Complete drawing on reverse side. <br />Signed Title: %��/YF/� Date: <br />l FO EPARTMENT USE ONLY <br />4 <br />Application Accepted byE ..Date — Area <br />r ! <br />Pit or Grout Inspection by Data final Inspection by Date <br />Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2000, Stk., CA 95201 A.� <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK <br />CASH <br />RECEIVED BY <br />DATE PERMIT"NO, <br />!� �-� <br />� <br />ark -1 �����t <br />