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' - APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL. HEALTH DISTRICT <br /> 1601 E. HAZELTON'AVE., STOCKTON, CA v <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> Local Health District, <br /> Job Address Cit Lot Size PM <br /> Owner's Name rQ4 Address ` a Phone 577,9 <br /> Contractor Address atmA G �.f?1 r Q�License Ntr_.�,W� ells Phonee <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 LINE <br /> FOUNDATION AGRICULTURE WELL ELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS <br /> ❑ Industrial . ❑ Open Bottom ❑ Me Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> !l Public n Other f-] Delta Depth of Grout Seal Type of Grout ; <br /> I I Irrigation Approx. Depth I } Eastern Surface Seal Installed by _ <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destr - n ❑ Well Diameter Sealing Material (top 50') <br /> Depth - Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIWADDITION l I DESTRUCTION,K INo septic system permitted if public sewer 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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> aDistance to nearest: Well Foundation Property Line <br /> - 1 <br /> LEACHING LINE ❑F. No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size " Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line i <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 Di§trict. <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 certify that in the performance of the work for which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applican ust call for all required inspections. Complete drawing on reverse side. <br /> Sig Title: -�� �"� Date: / <br /> ° <br /> FOR DEPARTMENT USE ONLY t r� <br /> Application Accepted by —1v ` Date Area 1 } <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 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEEO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ATE PERMIT'NO. <br /> � ���•••rrr <br /> i EH 13-24(REV.I?K 5) � � • ! <br /> EH 14-26 r <br />