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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 /> Local Health District. & <br /> made 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 /> , <br /> Job Address fit.►- T <br /> . — _ City ` Lot Size j <br /> i ^ f I .. PM <br /> Owner's Name Address �� � Qp��[, Phone <br /> Contractor � Address L7CJ A.1 License No: Phone3 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR .2" { OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK f <br /> SEWER LINES DISP05AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS- <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> PDia. of Well Casing <br /> ❑ Public <br /> 2-Domestic/is/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal r <br /> ❑ Irrigation Type of Grout <br /> ---Approx. Depth [IEastern G urface Seal Installed by <br /> Repair Work Done ,0' Type of Pump * .C.�y H.P,� State Work Done <br /> Well Destruction ❑ Well Diameter ! Sealing Material (top 501 �d <br /> Depth , Filier`Material 113elow 501 j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION ❑ INo septic system permitted if public fewer is <br /> ,. 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 <br /> SEPTIC TANK Water table depth <br /> ❑ Type/Mfg Capacity— <br /> No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method'of`Disposal <br /> Distance-to nearest: Well Foundation Property.Line s <br /> 1e <br /> LEACHING LINE ❑ No. & Length'of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line i <br /> SEEPAGE PITS ❑ Depth Size <br /> Number Y _- <br /> SUMPS __ ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ _ _ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with Sbn 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'shali not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractors 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 shallll�employ persons subject to workman's gcompensa- f <br /> tion laws of California." � >I <br /> The applicant st call f II required inspections. Complete drawing on reverse side. <br /> Signed Title: i <br /> DatG/ ,Y <br /> I FOR DEPARTMENT USE ONLY If <br /> Application Accepted by f.x <br /> Date �Area <br /> Pit or Grout Inspection by Date Final inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009,,Stk., CA 95201 - <br /> FEE AMOUNT DUEAMOUNt REMITTED <br /> INFO K RECEIVED BY DATE PERMIT"NO. <br /> + EH 13.24 iREV.,1/s 51 __ fy� P <br /> EH 1426 _ 1 C, 1 ��� S Q <br />