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r <br />` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> f PERMIT EXPIRES 1'YEARFROM DATE ISSUED <br /> 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 /> 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 /> Job Address `3 �� G /Z City c$G� Lot Size PM <br /> Owner's Name Address 4CG e.5 C-0-e e 2. Phone 416' £'oe 6. <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ W <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'Ll Industrial Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other I ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P f State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'} <br /> Depth Filler Material (Below 501 \\\ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRU ION (N septic system permitted if public sewer is <br /> -- --+ - - x M _ _ w Fav (able 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 feet: } <br /> P 1 Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well---Foundation_"Foundation -Property-Line. ; <br /> I f , <br /> LEACHING LINE ❑ No. & Length of lines 1 Total length/size <br /> -FILTER BED _ ' <br /> ❑ Distance_to nearest:...-.--Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS ❑ Depth ASizeNumher R r <br /> SUMPS 11 Distance to nearest: Well Foundation :Property_Line <br /> DISPOSAL PONDS ❑ <br /> 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 person in such manner as toj become subject to workman's compensation laws of California."Contractor's-hiring or sub-contracting signature <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." <br /> The applicant mu t call for all required inspections. Complete drawing on reverse side. <br /> a . <br /> Signed Title: /,ice 'Date: <br /> ! FOR DEPARTMENT USE ONLY <br /> Application Accepted by l Date � - Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 I <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 4 AMOUNT REMITTED C S RECEIVED BY DATE PEitMIT'NO. <br /> + EH 11425 Ev.1/a 5) <br />