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y APPLICATIOWFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT -,;;� rµ <br /> 1601 E. HAZELTON AVE.,.STOCKTON, CA <br /> Telephone (209) 466-6781 F <br /> PERMIT EXPIRES'l YEAR FROM .DATE ISSUED <br /> d. .K. (Complete.in Triplicate), r : <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. 73 ~ <br /> Job Address City Lot Sze dPM <br /> � Address <br /> 2— <br /> . 4 o <br /> Phon-eOwner's Name �a+remora ]� - _ <br /> /� <br /> Con ractorh0 Address-7-12,1 WeFp License No. U <br /> 5;?/PhoneVy. 2a <br /> TYPE OF WELL/PUMP: NEW WELL Cl WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS v <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 /> ❑ Irrigationt: ----Approx. Depth ❑ Eastern . Surface Seal Installed by r i <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 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION X (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 <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ , 1Method of Disposal 5' <br /> _ Distance to nearest: Well,- Foundation "r { Property Lihe <br /> LEACHING LINE ❑' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to ni earest: Well _ Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Num bar <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 /> 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 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 /> The applicant t call for all required ' ions. Complete drawing on reverse side. <br /> i Z <br /> Signed X 2 Title: t�/ Date: S 0 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Y Date In Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: l C1 . <br /> LJStk 466-6781 ED Lodi 369-3621 t.Manteca -823-71 ❑ Tracy 835-M5A3ja <br /> 1 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9520 <br /> INFO FEE AMOUNT DUE AMOUNT REMITTED CK AT CASH RECEIVED BY DATE PERMIT NO. <br /> EH 14-29 d O <br /> + EH 13-24 MEV.1/95) <br /> ��� <br />