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APPLICATION FOR PERMIT , <br /> AL HEALTH DISTRICT } <br /> SAN JOAaUIN LOC <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED F <br /> &<� C (Calrtplete in Triplicate). <br /> 1 Application is hereby made to the Sen 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 /> r Local Health District..,,. -- <br /> ` ciwRl PON Lot Size PM <br /> Job Address <br /> Owner's Name Address <br /> " Phone m � <br /> k Contractor <br /> License No. Phone <br /> 's Name S� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMO'INSTALLATIONVO" "` SYSTEM REPAIR-❑- OTHER ❑ <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 E] Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy <br /> Type of Casing Specifications <br /> I 11 Public <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout n <br /> ❑ Irrigation ---Approxi. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done L3 Type of Pump H.P. <br /> _ State Work Done <br /> t .l <br /> i Well Destruction ❑ Well Diameter Sealing Material stop 501 {� <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septicailable system <br /> y te200 feetitted if public sewer is <br /> r <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 /> 777 <br /> No. Compartments <br /> I SEPTIC TANK ❑ Type/Mfg SY <br /> PKG. TREATMENT PLT. C] j Method of Disposal -f <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> (( FILTER BED ElDistancer to nearest: Well Foundation Property Line <br /> l SEEPAGE PITS , + t_ ❑ -Dept_h Size Number <br /> SUMPS ❑ Distance to nearest: WellFoundation Property Line - <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 District. <br /> rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <br /> ompensation laws of California." Contractors hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's c <br /> certifies the following:"I certify 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 applicant ML Cy <br /> all for all required inspe ions. Complete drawing on reverse side. <br /> Signed Title: �'��N bate: <br /> €'r'1 <br /> FOR DEPARTMENT USE ONLY <br /> I/V Date / G � a h <br /> Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by l� S <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 160CAW <br /> E. Hazelton Ave., P.O. Box 2009, Stk., C , ::Cw r fCy <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE IT`NO. <br /> INFO , <br /> l.. + EN 3.24 EH 1426 iREV.101831 �,�` �Q �-� Trb ��p--S <br />