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e <br /> ' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ` Min; <br /> 1601 E'"FIAZELTON;AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> !PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <br /> I (Complete in Triplicate) �1V41kR0�ME-N-fAL HEALTH <br /> �,( }}��� (('� <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein de�cril5_ed11U9,W'pf eka I n 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 /> � &J4Jo ddress T Lot Size PM <br /> wn rAd <br /> t t dress r r Phone �� • �� <br /> j, 2 <br /> Contractor rensAA Zk <br /> _ L.icense No. 2 3p��-Phone <br /> TYPE OF WELL/PUMP: N WELL ❑ J.4_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 Specifications <br /> 1-1 Public In 1 Other a ❑ Delta Depth of Grout Seal Type of Grout <br /> qk <br /> I I Irrigation � App�ox:'Oept .s I I Eastern �uriace Seal Installed by <br /> Repair Work Done I* Type of Pump �w H.P. State Work Done_ s <br /> IF <br /> Well Destruction ❑ Well Diameter 9 , Sealing Material (top 501 <br /> Depth Fillef Material f Below 50'I <br /> 1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION 1 1 DESTRUCTION I ] iNo septic,system permitted it public sewer is r <br /> 1_t available within 200 feet.] <br /> Installation will serve: 'Residence— Commercial----­ E--Other% ' <br /> w 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.IC <br /> PKG. TREATMENT PLT. ❑ r � � � s Meth dlof Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines ' Total Iengthtsize <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll 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 son in s manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies t following: "I ce ify that in t performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- <br /> tion law of California." <br /> The ap licant u r all ion Comptete drawing or&Averse Q <br /> Signed X Title: ' Date: - <br /> FO"EPARTMENT USE ONLY <br /> Application Accepted by Date Area v <br /> Pit or Grout Inspection by Date Final Inspection b Date) <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy P335-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY / DATE PERMIT NO. <br /> a EH 13"24 1REV. <br /> EH 14-26 <br />