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i+. eP k <br /> s <br /> I APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON�AVE., STOCKTON, CA <br /> y" Telephone (209).466-6781 <br /> PERMIT EXPIRESI YEAR'FROM <br /> DATE-ISSUED" <br /> (Complete <br /> In,TnpljCgte� <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 SanJoaquin County Ordinance No. 549 for.sewage or No.,1862 for well/pYump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. �r u n•. . , <br /> 7f �,, °� •:�° kOf <br /> r �.. -. <br /> Job Address — ;7 i .; S ," City , <br /> Owner's Name Address - VPho <br /> Contractor Address <br /> — License No, Phone <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER E]DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> "-- - --FOUNDATION .=�. - <br /> 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 /> r <br /> Dia. of Well Casing ElDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> C1 Public C1 Other I] Delta Depth of Grout Seal - <br /> 11 Irrigation _ Type of Grout <br /> Approx. Depth ❑ Eastern,_,.__�„�..,_Surface Seal Installed by <br /> Repair Work Done 11 Type of Pump ! H.P. <br /> State Work Donla <br /> Well Destruction Well Diameter Sealing Material (top 50') { <br /> Depth Filler Material (Below 501) y <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ ;REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 1f available within 200 feet.) <br /> installation will serve: Residence— Cc merclalj Other i <br /> Number of living units: Number of bedrooms <br /> i <br /> Character of soil to a depth of 3 feet: 1 <br /> SEPTIC TANK ❑ Type/Mfg S Water table depth <br /> Capacity NoCompartments <br /> PKG. TREATMENT PLT. ❑ <br /> Meihod of Disposal - s ^=: <br /> Distance to nearest: WellFoundation Property Line <br /> LEACHING LINE ❑ No. & Length oP lines <br /> rest, Total Length/size _ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Pro <br /> -Property rty L ine <br /> SEEPAGE PITS ❑ "Depth !Size Number <br /> SUMPS ❑ Distance to nearest: ,Well Foundation Property Line <br /> ,a. DISPOSAL PONDS ❑ •�., ._ _ ..-.�_� <br /> Y I Hereby certify that I have prepared this application and tharthe work will be done in accordance with San Joaquin county ordinances,state laws, n <br /> rules and regulations of the San Joaquin Local Health District. x I <br /> Home owner or licensed agent's signature certifies the followin yfy v n pe i <br /> employ an g::'> 1,certi that in the rformance of the work for which this permit is issued, I shall not <br /> p y y person in such manner as to become subject;to workman's compensation laws of California."Coniractor'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, I'shall employ <br /> i tion laws of California." + y persons subject to workman's compensa- <br /> tion <br /> The applicantst c �Zaqflequ' i ctions. Co plate drawing on arse side. <br /> i <br /> Signed. Title:--- - rlr[.n.k.� - <br /> Date: __111 <br /> *—FOR-LIEPYiRTMENT'USE'ONLY-- <br /> Application Accepted by - r <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection b 1. ! <br /> p Date <br /> — —� ; Y <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 /> a <br /> r i <br /> FEE AMOUNT DUE - AMOUNT REMITTED <br /> INFO GASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24IREV.1/851 , <br /> EH 1426 O . f <br />