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w � <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 /> (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 Ryles and Regulations of the San Joaquin <br /> Local Health District. , <br /> Job Address 1,!�' I S �� (` City S l V_to Lot Size PM <br /> Owner's Name Address 5 V5, m F__J Phone <br /> r <br /> Contractor W m �fNIL.CJ)M4LA7Address License No.�a��Phone <br /> TYPE OF WELL/PUMP: NEW.WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS �A <br /> INTENDED USE TYPE OF WELL .._. PROBLEM AREA 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 /> ❑ Public ❑ Other __.4.❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth '❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter, v-Sealing Material (top 50'i <br /> Depth f Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION IWo septic system permitted if public sewer is <br /> I1. " - y 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 N---Type'/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation. Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well foundation Property Line <br /> DISPOSAL PONDS ❑ k <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. <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 /> mploy any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> c ifies 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 s of California.' <br /> he applic ust call for II requi d ins tions omT,4wing on r verse si e. <br /> Signe �.� Date: <br /> r-- <br /> r <br /> FOR DEPARTMENT USE'ONLY-. .yy <br /> Application Accepted by �/�� Date Area C/�/ 2— <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: -- --- - � - - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"N0. <br /> INFO <br /> +EH 13-24(REV,I/aW <br /> EH 14-26 '-'�7 <br />