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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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 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 /> Joh Address �19/ Lot Size PM <br /> � � - - <br /> Owner's Name V ascAddress __...� e ' Phone <br /> i <br /> Contractor "aw Address f0& 112 7 License No U 2-3 Phone ^!� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ ti DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 4 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SPOSAL FLD. PROP. LINE <br /> i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> 1 <br /> INTENDED USE TYPE OF,WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 7 <br /> i <br /> e`6­mestic/Private ravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout Se Type of Grout <br /> i I Irrigation �ppro x. Depth [,,Tastern / Surface Seal Installed by <br /> Repair Work Done. [ Type of Pump �� H.?. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t_ - <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.1 REPAIR/ADDITION I I DESTRUCTION I I iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> ' Installation will serve: Residence Commercial Other r <br /> �� Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 1 _ SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> i"fll PKG. TREATMENT PLT. ❑ 4F°\ Method of Disposal <br /> Distance to nearest: Well Foundation Property-Line <br /> f <br /> + S F <br /> 1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED LJ Distance'to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number z <br /> SUMPS ❑ Distanceto nearest: well Foundation Property Line <br /> DISPOSAL PONDS Cl <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." 11 <br /> The applicant mu II I require ins /n�/�Comp r I on reverse,C�ide. g <br /> Signed X YC/ le: i"� Date: <br /> F DEPARTMENT USE ONLY <br /> Application Accepted by r - �L Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ZZ <br /> Additional Comments: E <br /> ❑ Stk 466-6781 Cl Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 935-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUEL AMOUNT REMITTED CASH RECEIVED BY DATE PERM! NO. <br /> 51t U3 Q, <br /> { . 4 op <br /> EN <br /> ♦. <br /> PH 7 p <br /> 3-24 IRtiV.5/K 51 `O� '„ L•,4 !c.s.a �- a 5/ <br /> EH 10-2t1 1 {\ <br />