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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> E. 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> 1 (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 wekV pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City Lot Size PM <br /> Job Address <br /> Owner's Na==KL-- <br /> Address //-� PhoneContractor <br /> Address License No. Phone �^ <br /> TYPE OF WELLIPUMP: NEW WELL 71 WELL REPLACEMENT El DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> t 1' DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO DEAREST: S£P41C TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> WTENDED USE -TYPE S POECL PR5BCEM AREA "STRU T O ��li <br /> ❑ Open Bottom ❑ Manteca Dia. o Well Excavation <br /> Dia. of Well Casing <br />\ ❑ industrial ��-.-- ; <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack CI Tracy, _, k,� Sy-pe of sl Type of Grout <br /> P-1 Publl'Icy 11 Other i Ci Delta Depth of Grout Seal YP = <br /> APprox4Depth l I Eastern Surface Seal Installed by <br /> `'°`Repair�Wo 1?one ❑ Type of f ump —ivy <br /> H P State Work Done v <br /> Well Destruction Well Diameter3 _ Sealing Material top 50'i <br /> fff <br /> Depth Filler IVlaterial)Velow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITIO CV DESTRUCTION l I (Not optic hit system emitted if public sewer is <br /> Installation will servei 4 Residence_ Commercial Other _— <br /> i t I <br /> Number of liningunit : - tNum er1 of bedworrfs <br /> Water table depth <br /> Character of soil to a depth of fee <br /> SEPTIC TANK El Ty�fyi/{f1L Capacity No. Compartments <br /> ` <br /> PKG. TREATMENT PL . ❑ t' � �t Method of Disposal <br /> PKG. TREATMENT PL�. 0Distance to nearest: ;Veli Foundation Property Line <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length size <br />` r Pro (art Line <br /> Il <br /> FILTER BED � ❑ Distance to nearest: Well Foundation PI Y <br /> 1 ( <br /> SEEPAGE PITS I I I Depth Size Number 3 <br /> SUMPS I 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS I ❑ <br /> I hereby certify that11 =e prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations 4f the San Joaquin Local Health Di§trict. <br /> Home owner or kicens d agent's signature certifies the following: "I certify that in the performance of thework for which this permit is issued, I shall not <br /> to become subject to workman's compensation laws of California."'Contractor's hiring or sub-contracting signature <br /> employ any person inuch manner as <br /> certifies the following:i'I certify that in the performance of the work for which this permit is issued,I shall Xploy persons subject to workman's compensa- <br /> tion laws of California}" <br /> The applicant I all req ctions. Complete drawing on rave side. <br /> # Signed X Title: Date r <br /> FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> 4 Additional Comments: <br /> ElStk 466-6781 ❑ Lodi 369 3 Mante B23-7104 cy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> M <br /> FEECK RECEIVED By DATE "PERMI7'NO, <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> 17 <br /> r.EH 13-24{REV.iiK51 35'f7V <br /> EH 14-25 - <br />