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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT `\` <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA w !s <br /> ° Telephone (209) 466-6781 .4 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED L <br /> a L'S(Complete in Triplicate) <br /> Application is hereby made tothe San Joaquin Local Health District forathework ribed.This a <br /> made in compliance with San.Joaquin County Ordina a No.549 for sewage or No. 1862 forcwell/pump and/the ules and Regherein u ations off tthe SanLocal Health District .,.,, Es in- <br /> `Job Address a . <br /> of SizecJ"�' PM <br /> x Owner's Name �� _ Address 5�3! - <br /> Phone <br /> „�Contractor_1 - —vs yddress _ tJr <br /> °. License-No:14 30%AlPhone.W <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> T FOUNDATION — AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ; 1 � <br /> i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> LJDomestic/Private ❑ Gravel Pack Dia_of Well Casing <br /> ❑ Tracy Type of Casing - <br /> El Public 11 Other , Specifications <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> F-1Irrigation ---Approx. Depth E2Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. i <br /> State Work Dane <br /> Well Destruction ❑ Well _t- <br /> Sealing Material (top 50') € <br /> Depth <br /> TYPE OF SEPTIC WORK: NEW INSFiller Material (Below 501)' <br /> TALLATION p�-f}EPAIR/ADDITION ❑ DESTRUCTION ❑ fNo septic system permitted if public sewer is <br /> r Installation will serve: Residence Commercial available within 200 feet.) <br /> _ Other <br /> Number of living units: —/— Number of bedrooms,— t <br /> �. <br /> Character of soil to a depth of 3 feet: ' <br /> SEPTIC TANK �fiypa/Mfg fi f - Water table depth <br /> ) Capacity Q( � <br /> PKG. TREATMENT PLT. ❑ � �'� -No. Compartments <br /> Method of Di osaI <br /> Distance to nearest: Well PNIM Fo_ —_ PropertyLine <br /> undation <br /> LEACHING LINE Ue'l o. & Length of lines f <br /> Total length/size i <br /> FILTER BED L2Distance to nearest: Well <br /> Foundation �� property Line <br /> SEEPAGE PITS IiV Depth Size 3 rt <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation _ <br /> DISPOSAL PONDS El _ Property Line <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancesr 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 certify that in the performance of the;work for which this ermit is issued, I shall em Io <br /> tion of California.' P P Y persons subject to workman's compensa- <br /> The a plica u t call f all r uired i ape omplete raving on r verse std . <br /> Signed <br /> Title: ^ <br /> Date: <br /> FO DEPARTMENT USE ONLYWa <br /> Application Accepts y Date `1 f 11 <br /> Area <br /> Pit or Grout Inspect y <br /> Additional Comments: Date . Final Inspection by <br /> Date <br />€ � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE 24(REV.t/s5] AMOUNT DUE AMOUNT REMITTED <br /> W' INFO G RECEIVED BY GATE FERMaNO.' <br /> + EH 7�w <br /> EH 5426 <br />