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................................. t <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA j <br /> Telephone (209) 466-6781 , <br /> 'PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Corhplete 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 R41es and Regulations of the San Joaquin <br /> Local Health District. <br /> STC31 City�� T Lot Size PM <br /> Job Address �' � �� , QA� <br /> I ' <br /> Owner's Name <br /> Address �Phone <br /> J License No.93—y+� Phone ► 1 <br /> Contractor Address r a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION {�J <br /> PUMP-INSTALLATION ❑._._ fSY.STEM.REPAIR. ❑__ - -"" Y OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 <br /> Dia. of Well Casing (t7o <br /> Type of Casin Specifications <br /> ❑ Domestic/Private L3 Gravel Pack El Tracy yp 9 Type of Grout <br /> ❑ Public ❑ Other -O•Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of'Pump - <br /> H P. State Work Done <br /> Sealing Material (top 50'i <br /> Well Destruction ❑ Well Diameter g <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION D. .REPAIR/ADDITION ❑ DESTRUCTION ❑ aNailablelwitsystem <br /> ne200 feetitted if public sewer is <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3:feet: r, <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ TypelMfg _ 'Method of'Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Foundation Property Line <br /> Distance to nearest, Well <br /> r <br /> LEACHING LINE ❑ No. & Length of fines_ Total lengthlsize <br /> ` ' Property Line <br /> i FILTER BED � ❑ Distance to nearest:-:, ,,�Well� �=r-"' ��s. Foundation }. <br /> SEEPAGE PITS ❑ Depth Size Number <br /> I SUMPS ❑ Distance to nearest: Well Foundation R Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 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 /> 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." ! , Y <br /> The applicant must call for all-required inspections. Complete drawing on reverse side. : <br /> Title: <br /> •t ` Date: <br /> Signed <br /> FOR DEPARTMENT USE ONLY <br /> y <br /> `Date �`' fC�t � Area r <br /> Application Accepted-by <br /> Date Final Inspection by Date 6�! <br /> Pit or Grout Inspection by » <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 Cl Manteca 823-7104 ❑ Tracy 835-6385 <br /> F Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT NO. <br /> INFO' <br /> + EH 13-24(REV.1/8 5) 10 <br /> EH 14.26 <br />