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APPLICATION FOR PERMIT _�a. <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 11209) 466-6781 ! <br /> PERMIT EXPIRES 1 YEAR 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 /> Jab Address l City l Lot Size PM +I <br /> Owner's Name Address Phone <br /> Contractor ddress 6- ' !cense No.Z6Y3y—�-Phone 6ti <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT 1-1 DESTRUCTIO <br /> NJpk <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR.❑ OTHER ❑ <br /> i DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> f <br /> INTENDED USE TYPE OF WELL PROBLEMAREA CONSTRUCTION SPECIFICATIONS <br /> I ❑ Industrial ❑ Open Bottom ❑ Manteca -Dia. of Well Excavation Dia. of Well Casing <br />### ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DES RU10 (Neilsepei system <br /> permitted if public sewer is <br /> Installation will will serve: Residence_ Commercial — Other __- <br /> Number of living units: Number of bedrooms <br /> a <br /> Character of soil to a depth of 3 feet: Water table depth <br /> k SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ff PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line G <br /> c <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> k <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 /> ify 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 cert <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractees hiring or sub-contracting signature <br /> 4� 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 /> F The applicant must tali for all uired inspectio s. C mplete drawing on reverse side. <br /> Signed <br /> Title: Date: " — <br /> I , <br /> FOR TMENT SE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: i <br /> ElStk 466-6781 11Lodi 369-3621 ❑ Manteca 823-7104 ElTracy 83541385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT NO. <br /> INFO DeS� f1, <br /> + EH 1324IREV.1/e5) Jr' 3s 1../'� 3-3+Y7 <br /> Yi_ `4S1 <br /> EH 14-26 r -- -.- <br />