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APPLICATION FOR PERMIT now <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 wail/pump and the Rules and Regulations of the San Joaquin <br /> _ Local Health DistriictT /4 / �7 ]"��� City <br /> y/� <br /> vJ <br /> 72 � Lot Size PM <br /> Job Address � JN <br /> (O'S-a <br /> C�, _s-'r"5 i U <br /> Owner's Name Address �� 1 Phone <br /> Us--9`]L <br /> Contractor. <br /> IOr Address 27r �� n��l�/ `Q License No. 5 IZ2 `I Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f 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 Excavalton Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing /UL Specifications <br /> 11 Public ❑ Other 11 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — Approx. Depth I I Eastern Surface Seal Installed by lisl <br /> Repair Work Done U Type of Pump H.P. State Work Done _ <br /> ;,a,,, estruction ❑ Well Diameter _ __ Sealing Material flop 50'1 <br /> A (,{f Depth �/ Filler Material (Below 50'1 <br /> r' TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if publicavailable 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 feel Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. 6 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that 1 have prepared this application and that the work will be do 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 /> Cal the follow: : "1 certify that in the performance of the work for which this pephit is issued,I shall employ persons subject to workman's compensa <br /> tan laws of Ca- r a." <br /> The applica mu call for all r 'endJ/^spa Co to drawing on,reevverse side. - <br /> Sig/n�edC v" Title: Date: -� <br /> A. Fr •�<ed•-• s --,.)1� f FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date (`,l 4P? Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicat- Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> �e. .. � - , 1, -��„ �.•>,+ . e, — `• (� _�Lr,. 1-d� <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 2�IREV, <br />