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APPLICATION FOR PERMIT <br /> SAN JOAQUIN-LOCAL HEALTH DISTRICT <br /> 1601 E.�,AA-ALTO9oAVE ., STOCKTON, CA <br /> l Telephone (209) 466-6781 , <br /> 11PERMIT EXPIRES i YEAR FROM DATE ISSUED <br /> i <br /> } <br /> I (Complete in Triplicate <br /> App Ordinance No:549 for sewage or No.1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Application is hereby made to the San Jo 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 Coun <br /> Local Health District. y /r <br /> ttf CrtY <br /> -fie - PM <br /> Job Address <br /> Phone <br /> Address <br /> Owner's Name r <br /> L License No. � hone <br /> liUvv` ddress <br /> Contractor /WELL REPLACEMENT El DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: A NEW ELL ❑ OTHER 11PUMP INSTALLATION ❑ SYSTEM REPAIR C3OTHER <br /> LINE <br /> SEWER LINES �� DISPOSAL FLO. - <br /> DISTANCE TO NEAREST: SEPTIC TANK __—�- PITS/SUMPS <br /> j FOUNDATION �� <br /> AGRICULTURE WELL-� OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom [I Manteca Dia.bf-WeN Excavation <br /> ❑ Industr I Specifications <br /> q ❑ Tracy Type of Casing <br /> El 'mastic/Private ❑ Gravel Pack 41- Type of Grout <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Public Surface Seal Installed'by <br /> pprox. Dep ❑ astern � <br /> ❑ Irrigation H P "'State Work Done <br /> Repair Work Done Type of Pump <br /> Sealing Material {top 501 <br /> Well Destruction ❑ Well Diameter Filler Material (Below 501 <br /> h111 7 <br /> available within 200 feet.! <br /> TYPE QF SEPTIC WORK: NEW INSTALLATION ❑ REPAIRlADDITI4N ❑ pESTRUCTI4N ❑ iNo septic system permitted if public sewer is <br /> Installation will serye: Residence— Commercial— Other— <br /> Number of living units: Number of bedroomsWater table depth <br /> Character of soil to a depth of 3 feet: -+,Capacity�.�� No. Compartments <br /> SEPTIC TANK ❑ Type lMfg ,�` Method of Disposal <br /> PKG. TREATMENT PLT. 13 � `� Property Line�— <br /> Dista,ce to nearest: Well �' Founn dation <br /> - Total length/size <br /> LEACHING LINE ❑ No. & Length of lines Property Line�— <br /> Foundation- <br /> FILTER BED [3 Distance to nearest: Well <br /> Size "��'" J Number <br /> SEEPAGE PITS ❑ Depth Property Line <br /> o nearest: Well <br /> Foundation <br /> SUMPS ❑ Distance t <br /> I DISPOSAL PONDS ❑ <br /> I hereby certify that l have prepared this application and that the ork will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and reguI t, n Joaquin Local Health District. <br /> ce that in the performance of the work for which this permitisissued, I shall not <br /> Home owner icensed agent's ignature certifies the following: " - rtdy <br /> r vvhi this permit is issued,I-shall-employ persons subject to workman's compensa <br /> employ any arson in such manna _as to-became-subject to�v++erkm 's.00m cion.lav�rss.of..Califnfnia.':-CQntfactor�s.hiring-or•sub-contracting signature <br /> certifies thy foIr1Wing: r certify t in the Performa e o the `-, V t ",v, <br /> z <br /> tion laws f C0iornia." le ,ng n rave sid . <br /> The app canrmust o <br /> II f require spa i Date: <br /> Signed f <br /> FOR DEPARTMENT USE ONLY t <br /> Date {-� - Area <br /> Application Accepted b Date <br /> Date�� Final Inspection by <br /> Pit or Grout Inspectio Y <br /> Additional Comments: ❑ Manteca ffi3-7104 ❑ Tracy 835-63% <br /> ❑ Stk 4664AI1 <br /> El 369-3621 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1fi01 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> CKRECEIVED 8Y DATE PERMIT N0. <br /> j FEE AMOUNT DUE AMOUNT REMITTED CASH ..� <br /> INFO ' <br /> + EH 43-24 4REV.1/e 5] <br /> EH W20 - - - _- - - <br />