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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT , <br /> 1601 <br /> ISTRICT - <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 /> 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 /> a` t �� a t Qd `�f� AA, , <br /> , Job Address City + +` Lot Size al c nLU& PM <br /> I F 41 <br /> Owner's Name Address ._� � GV ` ZL4—' Phone <br /> Contractor's Name <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL Ll WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ _ _ __SYSTEM REPAIR ❑ f OTHER ❑ - <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL�FLD. PROP. LINE <br /> FOUNDATION is AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA y' CONSTRUCTION SPECIFICATIONS i <br /> EJ Industrial EJ Open Bottom EJ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy' Type of Casing ' <br /> Specifications <br /> ❑ Public ❑ Other k ,❑ DeltaDepth of Grout Seal Type of Grout <br /> ❑ Irrigation ___�4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Wel! Destruction © Well Diameterr,,..�-­Sealing-Material Itop 50'1 <br /> Depth f'r; Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ No septic system permitted if public sewer is <br /> arm : M available within 200 feet.) <br /> Installation will serve: Residence Commercial- Other <br /> j 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—A259 r0 No. Compartments .� <br /> PKG. TREATMENT PLT. 11 't ,¢: �' m <br /> � f Method of Disp9sal <br /> Distance to nearest: L Well�G—,Foundation� -74 Property Line _ _ <br /> LEACHING LINE & Length of linena� Tptal length/size <br /> FILTER BED ❑ Distance to nearest: { Well 44 Foundations property Line <br /> 1 <br /> r <br /> ;SEEPAGE PITS ❑ Depth Size r" �� Number <br /> SUMPS D Distance to nearest: WellFoundation Property Line <br /> 'DISPOSAL PONDS EJi <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, arid" , <br /> 4rules and regulations of the San Joaquin Local Health District. <br /> l;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 m st call for all require i etions. Compiete dr`wing on rev; a side. <br /> Signed <br /> �L IL I Date: <br /> l FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �`+1 ^Area <br /> ,Pit or Grout Inspection by Date Final Inspection by Date " ` <br /> 'i <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. azelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> + INFO CA RECEIVED BY DATE PERMIT'NO. <br /> + <br /> EH 1428 EH'W25 tREV.1U7831 JI <br /> _ f} <br />