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e . <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEITON 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 Rules and Regulations of the San Joaquin <br /> I Local Health District <br /> � � � <br /> Job Address _ � 12ry l 76 City�&&Al Lot Size PM <br /> Owner's Name Address <br /> Phone <br /> I' <br /> Contractolk ress License No 3, 2 Phone; <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WECLAEPLACEMENT Q DESTRUCTIO <br /> PUMP INSTALLATION El SYSTEM REPAIRI❑ OTHER 14 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL 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 Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal T <br /> ype of Grout <br /> ❑ Irrigation _—Approx. De th ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum -H.P. State Work Done <br /> Well Destruction ❑ Well Diameter '^' Sealing Material (top 501 ' <br /> Depth Filler Material-(Below ' <br /> TYPELQZ SEPTVWORK:. NEW INSTALLATION LJREPAIR/ADDITION ❑., DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) , <br /> Installation will se Residence Commercial_ Other <br /> i <br /> Number of living units: mbar of bedrooms <br /> Character of soil to a depth of 3 feet: i Watei table`depth <br /> l <br /> SEPTIC TANK ❑ Type/Mfgr CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ ` Method of Disposal d <br /> Distance to nearest: Well dation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 1bul. ength/size <br /> FILTER BED ❑ Distance tb nearest: Well Foundation Pro Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 Joaquiri Local Health District. <br /> Home owner or licensed abent'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." Contractors hiring or sub-contracting signature <br /> certifiesLthe following:"I certify that:�inspections. <br /> rformance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion lawCalifornia." <br /> The appnt call fo II r Complete drawing on arse side. <br /> Signed Title: _ G r Date: <br /> I FO EPARTMENT USE ONLY <br /> i .i �f <br /> Application Accepted Date Area <br /> 61 <br /> Pit or Grout Inspecti ate Final Inspection by per® _�7 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 368-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + E 13-24 IAEV.i/a 51 —9 I <br /> EH 14-M. ® �� �!7 <br />