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i 1 <br /> APPLICATION FOR PERMIT . <br />! SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON,.CA <br /> r Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 r <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 /> City Lot Size PM <br /> Job Address w* <br /> I sa,+ <br /> I, Address Phone <br /> Owner's Name <br /> License No. Phone ; <br /> Contractor's NameAL tAt "` .a <br /> TYPE OF WELLIPUMP: NEW WELL LJWELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM PAIR ❑ OTHER ❑ Vim° <br /> F <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES �— DISPOSAL FLD. PROP. LINE <br /> FOUNDATION1AGRICULTURE WELL OTHER WELL PITS/SUMPS f, <br /> INTENDED USE TYPE OF WELL PROBLEM AREA (CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ' <br /> L) industrial El Open Bottom El Manteca r` Dia. of Well Excavation <br /> Specifications _ <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Type of Grout <br /> ❑ Public F3 Other ❑ Delta Depth of Grout Seal Yp <br /> ❑ irrigation ---Approx. Depth ❑ Eastern Su d e Seal Installed by <br /> G \ <br /> Repair Work Done ❑ Type of Pump H.P. State Work pone ' <br /> Well Destruction ❑ Well Diameter, r Sealing Material (top 501 <br /> Depth 1 Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ DESTRUCTION-0 (Nailableo septiw h nern <br /> 2G0 feet.) <br /> itted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> + Water table depth <br /> Character of soil to a depth of 3 feet: <br /> ' - Capacity No.Compartments <br /> SEPTIC TANK ElType/Mfg ". k - <br /> t PKG. TREATMENT PLT. ❑ Method-of Disposal <br /> Distance to nearest: Well �-Foundation Property Line , <br /> LEACHING LINE El No. & Length of lines Total length/size <br /> FILTER BED ❑ Distanceto nearest: VYell Foundation Property Line <br /> I <br /> f SEEPAGE PITS 171Depth size_:LNumber <br /> I SUMPS ❑ Distance to nearest:: Well Foundation Property tine <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 have prepared this application and.that the work will be done in accordance with San Joaquin county o dingy cines, state laws, and <br /> k rules and regulations of the San Joaquin Local Health District, T <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 /> such manner as to become subject-to-workman's compensation laws of California."Contractor's hiring or sub-contracting'signature <br /> employ any person in s <br /> h certifies the following: certify that s the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> i tion laws of California." <br /> The:pplicantrrlust cal for all re uire i pe tons. Complete drawing on rave e side.f1 " ,�. Date:Signd 7it1e: r L' <br /> F - <br /> R DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by Q _ <br /> Date Fina inspection by�r �6ate <br /> Pit or Grout Inspection by <br /> Additional Comments: <br /> [I Stk 466-6781 E) Lodi 33621 1-] Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK <br /> FEE <br /> RECEIVED BY DATE PERMIT'N0. <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH <br /> . <br /> INFO <br /> +EH 13-24(REV.141831 <br /> EH 14-28 =-3 <br />