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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 1 YEAR FROM DATE ISSUED <br /> A 4. (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 /> y, 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 t " – • v City _ Lot Size PM <br /> gn— <br /> Owner's Name I ■ �� �L + Address t{ - Phone <br /> ' <br /> Contractor v" t�� Address M • '�r Li a No. 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 WEL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYP WELL PROBLEM AREA CONSTRUCTION SPECIFIC TJ # l <br /> Industrial pen Bottom 1-1Manteca Dia. of Well Excav tion r Dia. of Well Casing <br /> ❑ <br /> ❑ Dome Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ P is ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> A JA <br /> Irrigation —Approx. De l EE Surface Seal Installed by <br /> Repair Work Done C1Type of Pump / H•P• O State Work Done AN 1111i4c, <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> t Depth Filler Material (Below 501 <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: Residence, Commercial other I <br /> 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 . No. Compartments <br /> PKG. TREATMENT PLT. 171 - ; Method of Disposal o <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line y <br /> SEEPAGE PITS ❑ Depth Size Number C <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 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 /> certifies the following: "I 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 applic t II a uir s ions. Complete drawing onrseside. - � ^ r`...�. <br /> Signed Title: Date:G v Y G <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date to ' Area <br /> Pit or Grout Inspection by Date Final Inspection by Date �– <br /> r ` t o <br /> i <br /> Additional Comments: ~ <br /> PLStk 466-6781 Lodi .369-3621 ❑ Manteca 7104 ❑ Tr&y 8356385 <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 CASH RECEIVED BY DATE PERMIT''NO. <br /> INFO <br /> 3S !:: <br /> lJ Ia—�3— 8[d�co4 <br /> + EH 13-24 MEV.1/a 57 !j(J <br /> EH 14-26 <br />