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APPLICATION FOR PERMIT <br /> r <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 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 Xmit 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 /> f !r t ! ! <br /> Job Address V C G City Lot Size PM <br /> Owner's Name �^ '� 2 ` <br /> Address /!G pY - Phone <br /> Contract k LK Address' License No.f f. ! Phone, 3 "l0& <br /> TYPE OF WELL/POMP: NEW WELL J�` 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 /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Ir ❑ Industrial VOpen Bottom ❑ Manteca Dia. of Well Excavationr �r <br /> v Dia. of Well Casing <br /> I] Domestic/Private ❑ Gravel Pack, ❑ Tracy Type of Casing A-are - QSS Specifications <br /> M Public iJ Other Cl Delta Depth'of Grout Seal Gi' 0 _ Type of Grout iCe4 .� <br /> PI(Irigation _3eC �.Approx. Depth [ I Eastern Surface Seal Installed by <br /> Repair Wotk-Done ❑ Type of Pump H,P. State Work Done_ <br /> Well Destruction ❑ Well.Diameter �z�_le Sealing Material (top 50') <br /> Depth /S�z Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'I REPAIR/ADDITION f-I DESTRUCTION I I (No septic system permitted if public sewer is p ' <br /> available within 200 feet.) RR + <br /> Installation will serve: Residence' Commercial= Other <br /> Number,of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth I <br /> SEPTIC TANK EJ Type/Mfg Capacity � �� 'No. Compartments i <br /> PKG. TREATMENT PLT. ❑ <br /> - Method of Disposal ^ <br /> s Distance to nearest: Well Foundation Property Line <br /> � F <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Eine I <br /> SEEPAGE PITS { I Depth Size Number <br /> SUMPS I1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS, ElJ - <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 /> 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 subcontracting signature <br /> t <br /> certifies the following: "I certify that in the performance of the work for which this permit is issuedI shall employ persons subject to workman's compensre <br /> tion laws of California." , <br /> r <br /> The applicant or all r fired actio Complete drawing on reverse side. <br /> r .. <br /> signed Title: <br /> - Date: I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � -^� Date f'- Area i <br /> Pit or Grout Inspection by Date Final Inspection by Dale T a <br /> Additional Comments: Alf <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> + EH13-24 iREV.I/e 51 <br />