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APPLICATION FOR-PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA } <br /> Telephone {209} 466-6781 <br /> [PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> I (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 /> Job Address f . 2 PO loko p � i 1 f <br /> City Lot Size qPM <br /> f .. . Owner's Name Address" <br /> ddess f Phone ! " <br /> ... <br /> AL�� <br /> Contr <br /> actor's Name License No. <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK:= SEWER LINES, DISPOSAL FLD. PROP. LINE ` rY { <br /> FOUNDATION i AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL{ PRbBLEM AREA--CONSTRUCTION SPECIFICATIONS f 1 <br /> r ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation ~� E <br /> Dia:of Well Casing <br /> ❑ Domestic/Private D Gravel Pack' ❑ Tracy_ . r Type of Casing5pecificat!on- <br /> ❑ Public ❑ Other ' O Delta— Depth of Grout Seal <br /> ❑ Irrigation Type of Grout <br /> g _.-Approx. Depth ❑'Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump kH.P. """ °�"�' '"'"" r, 'Sta'te WorK'Done j• s <br /> Well Destruction C1 Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200'feet.) <br /> Installation will serve: Restonce _ Commercial'— Other ^�� <br /> " k Number of living units: Number of bedrooms <br /> {'I Character of soil to a depth of 3 feet: NONA <br /> - Water table depth <br /> r` y SEPTIC TANK �' Type/Mfg �°.C.r-� :� _ Capacity f <br /> PKG. TREATMENT PLT. ❑ No. Compartments, I <br /> Method of Disposal <br /> - Distance'to nearest: Well 42-:2 Foundation ld Property Line ` <br /> LEACHING LINE No. & LengthFof lines -=I Total length/size o " <br /> FILTER BED ❑ Distance to nearest: Well <br /> #{. Foundation Property Line vy <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 /> 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 /> or w <br /> certifies the following: "I certify that in the performance of the work for this permit is issued,I shall employ persons subject to workman's compel <br /> tion laws of California." <br /> The applicant must call r all i pired ' pe Ions. C plate drawing on reverse side. �- # <br /> Signed G,��V f A ►/ <br /> Title: Date: 1, <br /> FOR DEPART ENT 115E ONLY <br /> Application Accepted by Date—,=5f��2� <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by n <br /> Date_ - / <br /> Additional Comments: <br /> ❑ Stk 466-6781 . ❑ Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 1 <br /> �I FEE AMOUNT DUE I AMOUNT REMITTED CIC# <br /> INFO RECEIVED BY DATE PERMIT NO. <br /> t R ry <br /> + EH 13-24(REV.101831 <br />-,,SEH 1428 <br />