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APPLICATION FOR PERMIT <br /> ,. SAN JOAQUINLOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> s. <br /> in County Ordinance No.549 for sewage or No. 1862 for we111pump and the Ryles and Regulations of the San Joaquin <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. f the application is <br /> made in compliance with San Joaqu tY .i <br /> E Local Health District. <br /> ,(� k City Lot Size PM` <br /> Jab Address //1' Y�.. igA <br /> Owner's Name <br /> Contractor <br /> Address <br /> License No._Phone <br /> d <br /> TYPE OF WELL/PUMP: NEW WELL Ll REPLACEMENT IJ DESTRUCTION ❑ <br /> a PUMP INSTAL LA 0 OTHE ❑ <br /> SYSTEM REPAIR ❑ ���� RI <br /> SEWER LINES DISPOSAL FLD,16 PROP. LINE i <br /> DISTAN E Ts 0 NEAREST: SEPTIC TANK P <br /> } FOUNDATION ` r AGRICULTURE WELL OTHER WELL— <br /> INTENDED <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> C1 Industrial ❑ Open Bottom ED Manteca Dia. of Well Excavation Specifications <br /> ` T e of.Casing <br /> s <br /> El Domestic/Private ❑ Gravel Pack ❑ Tracy Yp. . Type of Grout <br /> ❑ Public ❑ Other ❑ Delta De ptR'of Grout Seal <br /> '" _ �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> ❑ irrigation - State Work Dane f <br /> Repair War 'Type of Pump �'-' .,�—H•P. r <br /> Sealing Materia ;top 50'1 l <br /> Well Destruction El Well Diameter g <br /> Depth Filler Material [Below 50') G <br /> TYPE OF SEPTIC; NEW INSTALLATION El REPAIR/ADDITION C1 DESTRUCTION ❑ (vailabi witseptic h ne200 feet.)permittif public sewer is , <br /> l <br /> Istallation will serve: Residence— Commercial Other <br /> k N <br /> Number of living units: F Number of bedrooms Water ta61e depth <br /> Character of soil to a depth W3 feet: No Compartments <br /> SEPTIC TANK ❑ Type/Mfg Capacity <br /> Method;of Disposal ► 1"' <br /> PKG. TREATMENT PLT. ❑' `{ i Cy / <br /> Distance to nearest: Well • Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines, ' Total length/size <br /> ' 1 Fou <br /> FILTER BED El Distance to nearest:. Well .ndation Property Line.ter_ � t <br /> i F Number 3 <br /> SEEPAGE PITS ❑ Depth ! Sae.: t- ---ti Property Line <br /> ❑ Distance to nearest: Well Foundation j <br /> f SUMPS <br /> DISPOSAL PONDS ❑ ' <br /> i I hereby certify that I have prepared this application' that the"work will be done in accordance with San Joaquin county ordinances, state __j <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owrier-or"licensed(agent's-signature-c6hifies-the following:-"! dertity"Ahafin the`laws of Cnce rn`ahe work for which this permit is issued, 1 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 /> i 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." <br /> The applicant m I for al quiV ins pe ns. :ompley d in on reverse side. Z4/ f1Qr� <br /> U f <br /> f !!Y . . . Date <br /> Signed : — <br /> FOR DEPARTMENT USE ONLY / <br /> Date a <br /> Application Accepted by <br /> Date <br /> *Pit or Grout Inspection by Date Final Inspection by <br /> - <br /> i Additional Comments:' F <br /> 4 <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835 6385 <br /> EI Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009. Stk., CA 95201 <br /> I. PERMIT'NO." ; <br /> AMOUNT DUE AMOUNT REMITTED RECEIVED-BY DATE <br /> FEE ° CASH <br /> -INFO <br /> +EH 13-24(REV. <br /> EH 14.26 r <br />