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APPLICATION FOR PERMIT <br /> i � SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE,, STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I'YEAR FROM 'DATE ISSUED <br /> (Complete in,Triplicate)" <br /> Application is hereby made to the San Joaquin Local Health District fora 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 <br /> Local Health District. I and the Ryles and Regulations of the San Joaquin <br /> % ;. , <br /> Job Address _2 7- 6 r; w, ,I , <br /> j # City 'Lot Size PM <br /> Owner's Name Address�� 7�{/ � � v�� wZ� <br /> Phone!Y74L <br /> Contractor �� p <br /> Address a License No. .> lc — Phone'` <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 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 „ ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> I9(pomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> 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 Diameteru Sealing Material Itop 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg t <br /> Capacity No. Compartments. <br /> PKG. TREATMENT PLT. ❑ ' <br /> Method of Disposal t ti <br /> Distance to'nearest, Well Fo d't`ion 7 Property Line '{ <br /> LEACHING LINE ❑ No. & Length of lines — -- _ Total length/size <br /> FILTER BED ❑ Distance to�nearest: Well Foundation Property Line <br /> a j <br /> •SEEPAGE PITS ❑ Depth € Size Number <br /> SUMPS ❑ Distance to'nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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-Dist"rict. ""`"4 _ <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."%Contractoes hiring or sub-contracting signature <br /> certifies the following:"I certify that in the'performance of the work for which this-permit is'.issued,f shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The q applicant mus for all re aired ins' 'pections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> F R DEPARTMENT USE ONLY 9' <br /> Application Accepted by' !!r " W Date —if 9 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> i <br /> ' Additional Comments: <br /> EI Stk 466-6781 ❑ Lodi 369-36211 El Manteca 823-7104 ❑ Tracy 835-6385 t <br /> Applicant- Return all copies to: Environmental Health Permit/Services'1601 E. Hazelton Ave.,"P.O. Box 2009, Stk., CA 95201 I <br /> FEE AMOUNT DUE AMOUNT_REMITTED CK# <br /> CASH <br /> INFO RECEIVED BY DATE F+ERMIT'NO." <br /> /y <br /> .+ (REV.l/s 51 <br /> EH 1426 �/ a <br /> q t <br />