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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN .LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA <br /> Telephone (209) 466-6781 ,+ <br /> PERMIT EXPIRES 1 YEAR FROM DATE .ISSUED g �, <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 /> . .. <br /> Job Address City Lot Sizery 4 PM <br /> Owner's Name _ Address Phone <br /> n . <br /> Contractor Address <br /> T�Z Tt �cGa <br /> A t� <br /> a <br /> License No. Phone`1' �746�x <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> E❑ Irrigation _Approxi Depth , ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 13Type of Pump H.P. _ T State Work Done_ 00 <br /> Well Destruction ❑ Well diameter Sealing Material (top 501 9 <br /> Depth --Filler Material IBelow 501 J <br /> TYPE OF SEPTIC WORK: NE11V INSI'ALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ <br /> (No septic system permitted if public sewer is tt <br /> available within 200 feet.l <br /> Installation will serve: Residen_ce..�- Commercial_ Other 1?ZAe gCwZ­ <br /> I Number of living units: ` Number of bedrooms 4%0 . /Nf��C! <br /> Character of soil to a depth of 3 feet:. ` r Water table depth <br /> SEPTIC TANK ❑ T <br /> ype/Mfg: ! Capacity No. Compartments � } <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal ' +r <br /> Distance to neare t:-Wel! =Fojndation Property Line ` <br /> I I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance tpo nearest: Well [ Foundation Property Line <br /> F <br /> -SEEPAGE PITS ❑ 'Depth � rSize -- -� � Number _ <br /> SUMPS ❑,.Distance ib nearest �'UUelf �' ' Foundation Property's ine�` �• <br /> DISPOSAL PONDS ❑ I <br /> 1 hereby certify that I have prepared thisapplication 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 cern that in the performance of the work for which 9 certify pe a rch this permit is issued I shall employ - <br /> Pe p y persons subject to workman's compensa <br /> tion laws of California:" _ <br /> i <br /> The applicant must all iofocins. Complete drawing on reverse side. <br /> Signed <br /> 9 TiTitle: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area & 7 <br /> Pit or Grout Inspection by Date Final Inspection byDate �l/ 4 <br /> Additional Comments: e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environ <br /> mental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE1 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH* RECEIVED BY DATE PERMIYNO. <br /> i EH 13-24(REV,r/n 5) <br /> EH 14-28Q <br />