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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 <br /> A. <br /> r (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. 1b62 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. // 11 <br /> _Z9171 7. r r�C �J <br /> Job Address <br /> Ci Lot Size PM <br /> Owner's Na l /' Address Phone <br /> Contra nr (_ii Address ! �' �. License No L Phone —�q q I <br /> TYPE OF WELL/PUMP: NEW WELL 11 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 /> 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 S i <br /> pecifications ,� P <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation <br /> --Approx.'pep Eastern Surface Seal r,stalled by Op <br /> Repair Work Done ❑ Type of Pump � H.P. _`' L`�/3' State Work Done 2n fka-1--1 , <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') V <br /> Depth Filler Material (Below 501 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (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. ❑ f Method of Disposal ' <br /> a <br /> Distance to nearest: Well Foundation Property Line � <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth J Size Number <br /> SUMPS El 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."Contractors hiring or sub-contracting signature <br /> certifies the follo 'ng: "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 C rfarnia." <br /> The applican7 mu 1t call for all r9equired in�spectio s. ompl a drawing on re side. <br /> Signed ' Title: <br /> Date' <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted G <br /> Date <br /> Pit or Grout Inspection by Date Final In <br /> spection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83546385 <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 <br /> INFO � ^ /] CASH RECEIVED BY DATE PERMIT N0. <br /> + EN 13-24 fREY.t/e5) <br /> EH 14-28 <br />