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APPLICATION FOR PERMIT <br /> 5 <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT I <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 <br /> PERMIT EXPIRES 11,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 here6 dAt&ibed.This,applicatign is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for well/pump and the Rules and Rebulafi6nsldt'th'&San Joaquin <br /> Local Health District. _ J <br /> Job Address ' C Lot Size PM <br /> Owner's Name Phone <br /> ,.. I <br /> Contract ss License No. Phone <br /> .. <br /> E TYPE DF WELL/PUMP: <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 171 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR_-*� 'OTHER E! ' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <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 Specifications <br /> I'1 Public Cl Other (-1 Delta Depth of'Grout Seal Type of Grout _._. <br /> I i Irrigation _Approx. Depth I I stern Surface Seel Installed by - <br /> Repair Work Done I1r Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> I Depth Filler Material (Below 501 —_ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l I DESTRUCTION i I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> j 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 /> j PKG. TREATMENT PLT. ❑ Method of Disposal <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 />{ <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS it Distance to nearest: Well Foundation Property Line <br /> I DISPOSAL-PONDS 1-1 <br /> i <br /> 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 d agent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> l employ any rson in su manner as to become subjec workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> I certifies t following: "I c if that in the o a o thel;wo ich this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion law of California"I <br /> The a licant st call f all re ed o . Camp to drawing o r side <br /> �.� •� - � .� �� � �� <br /> � <br /> j Signa X Title: i Date. <br /> FdR—PILTARTMENT USE ONLY <br /> Application Accepted by Date ��� Area <br /> Pit or Grout Inspection by Date Final Inspection by lfole �lt.. Datel;; A-8-le <br /> a Additional Comments: <br /> © Stk 466-6781 ❑ Lodi 369-3621 0 Manteca 823-71.64 ❑ Tracy 836-6385 <br /> Applicant -'Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />'I FEE AMOUNT DUE AM NT REMITTED CK .RECEIVED BY DATE PERMIT ND. <br /> k INFO CASH <br /> ♦.EH17-241REV.r/H51 z� �j �! �] / �( � <br /> EH i4-2f3 rcc.J// / Zl <br />