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APPLICATION FOR PERMIT - <br /> i <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> . <br /> 1.601 E. HAZELTON AVE.,aSTOCKTON, CA <br /> Telephone (209) 466-6781 <br /> i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDy x �� fi <br /> (Complete imTriplicate) . ,,. y <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 /> Job Address <br /> City G �- Lot Size PM <br /> Owner's Name ° tri Address Phone <br /> p Ad <br /> Contractor - <br /> --�f�� G I~ dress t� m w License No. Phone o� + <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> i PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: .SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> ! FOUNDATION I 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 <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public- -^- L] Other C1Delta Depth of Grout Seal <br /> LJ — <br /> Irrigation� T A Type of Grout <br /> --Approx. Depth ❑ Eastern Surface Seat Installed by ! , <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done_ <br /> Well Destruction ❑ Well Diameter "f <br /> ,,..Sealing"Material Itop 50' <br /> Depth FillerMatrial <br /> O <br /> (8elow 50'),...--. .---- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑l(No septic system permitted if public sewer is <br /> 1 t + available within 200 feet.) <br /> Installation will serve: Residence Commercial Other ` I <br /> Number of living units: <br /> Number of bedrooms <br /> Character of soil.to a_depth" 3-feet: <br /> Water table depth <br /> SEPTIC,TANK [� Type/Mfg <br /> PKG. TREATMENT PLT. Ll Capacity No. Compartments C L} <br /> Method of Disposal f <br /> -~-----�--�.-Distance to-nearest: ; Well Foundation=jii�—' property Line_3 <br /> i <br /> LEACHING LINE No. & Length of lines 14---^ W d <br /> To al length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> f s Foundation �_ Property Line <br /> SEEPAGE PITS <br /> ❑" Depth Size Number <br /> SUMPS. <br /> ❑ Distance to nearest:" Well - Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> eL <br /> I hereby certify that I have prepared this application and that the work will be'done in maccordarice'with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health District. f <br /> Home owner or licensed agent's signature certifies the fol i—I ` <br /> employ an g: "I certify that in the performance�of the work for which this permit is issued, I shall not <br /> p y y person in such manner as to become subject to workman's compensation laws of Califorriia-"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 must call for all r quired inspections. Complete drawing on reverse side. <br /> Signed XTitle: <br /> 4 Date: <br /> FOR DEPARTMENT USE ONLY <br /> s <br /> Application Accepted by 7s <br /> Dater Area <br /> 4 <br /> Pit or Grout Inspection by <br /> ate Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 O,Tracy".835-6385. <br /> Applicant- lletum all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. 80;2009, Stk., CA 95201 <br /> FEE <br /> AMOUNT.-DUE AMOUNT REMITTED- <br /> INFO �CASH RECEIVED BY DATE- PERM T'-NO. <br /> .'.+ 711 <br /> EH 14-28 LfEH13-24{REV.iin5) - - <br /> 7 6/ <br />