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APPLICATION FOR PERMIT 1 , <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <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 /> t made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1862 for welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> ddress Phone <br /> Own er's Nam ~ <br /> Co tractor Addres License d P � ��� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> it PUMP INSTALLATION 13 SYSTEM REPAIR LJ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE, TYPE OF WELL PROBLEM AREA CONSTRUCTIO' ' CATIONS <br /> ❑Flndustrial k ❑ Open Bottomr y �❑ Manteca D, ell Excavation Dia. of Well Casing <br /> T.. e of Ca' � ' Specifications <br /> ❑IDomesticl Private k 0 Gravel Pack ❑ Tracy � VP 9 � <br /> 44 x. Type of Grout <br /> I ntPublic in Other +? +! eta Depth of Grout Seal <br /> r.. <br /> I l�Irrigadon �`� �_.Appr th I i'Eastern ; Surface Seal Installed by— <br /> I <br /> x^r. State Work Done _ <br /> Repair Work Done Liof Pump H.R. <br /> Well Destructio Well Diameter t Sealing Material (top 501 <br /> i <br /> Depth Filler Material I Balow 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTIO INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> installation will serve: Residence— Commercial_ Other <br /> F iNurnber of living units: Number of bedrooms <br /> Charactef of soil to a depth of 3 feet: Water table depth <br /> SEkkkkkkPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line " <br /> rf ` r Total len th/size <br /> LEACHING LINE ❑ No. & Length of lines g <br /> Ft LTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS [ I Depth Size Number <br /> t p; <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> ! DISPOSAL PONDS ❑ <br /> I Ihereby 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 /> Con <br /> employ any person in such manner as to become subject to workman's compensation laws of California." tctor s hiring or sub contracting signature <br /> ra <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." +� t <br /> The applicant st call for all required i s ctions. Complete drawing on rev <br /> .x '. ., *,,.. <br /> Of— <br /> .Title: Date: <br /> Signe <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> ��. <br /> Pit or Grout Inspection by Date Final Inspection by Date_ <br /> Additional Comments: <br /> © Stk 466-6781 ❑ Lodi 369-3621 © Manteca 523-7104 ❑ Tracy 835-6385 <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 CASH RECEIVED BY DATE PERMIT`NO. <br /> INFO 9 �7p h�/Jjr, <br /> ♦.f:H 13-24lttEV. /n51S' L�l S_���� <br /> fH 14-2a <br /> i <br />