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!� APPLICATION FORx MIT rVS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> vw E Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE 1SSUED . <br /> �a (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. TMs application is l <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. ii A <br /> Job Address Y ' <br /> City t Size" Ply <br /> Owner's Name Address <br /> Phone <br /> ;; f <br /> Contractor, �76 1` Address ` �N License No. C) Phone OZ <br /> TYPE OF WELL/PUMP: �'i NEW WELL)O'% WELL REPLACEMENT ❑ DESTRUCTIQN ❑ <br /> PUMP INSTALLATION [ SYSTEM REPAIR OTHER Ll <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. I PROP. LINE <br /> FOUNDATION I't 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 Wel! Casing <br /> Domestic/Private ❑ Grave! Pack ❑ Tracy Type of Casing {specifications �j <br /> " <br /> L1 Public ❑ Othher ❑ Delta Depth of Grout Seal Type of Grout } <br /> ❑ Irrigation --Rpprox. Depth Eastern Surfac Seal Installed by .J <br /> Repair Work Done X_ Type of Pump H.P. r Q <br /> State Work Don ! <br /> " <br /> Well Destruction ❑ Well Diameter Seating Material /top 50'1 : <br /> Dept h�P -- -- ;-- Filler Material {Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residerice Commerciale Other <br /> Number of living units: i� Number of bedrooms #t <br /> Character of soil to a depth of 3 feet: ! I <br /> ! l , _Watertable!depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG.,TREATMENT PLT. ❑ Method o Disposal <br /> 3 . <br /> i Dis'alce to nearest: Well Foundation Property Line_�_ r <br /> u i ! <br /> LEACHING LINE ❑ No'";& Length of lines <br /> ti g Total length/size !� i <br /> FILTER BED ❑ Distance to nearest: Well Foundation '� Property Line <br /> SEEPAGE PITS ❑ Depths Size" Number f k <br /> SUMPS ❑ Distiiance.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. l i <br /> Home owner or licensed agent's signature certifies the fallowing: "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 toting 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." e! y <br /> I, I <br /> The ap st call for all r uired i ctio Complete drawing n reverse'side: , t ' 1 <br /> I� <br /> Signed Title: �� <br /> I Date: <br /> 11 FOR DEPARTMENT USE ONLY <br /> Application Accepted Oat, AreaJPT <br /> O <br /> E <br /> Pit or Grout Inspecti n by R Date Final Inspection by C�n r 4 Date P-16-19 <br /> Additional Comments: fJ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 - ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IIS <br /> _ FEE AMOUNT:DUE� AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> '+EH 13-211REV.i/N51 7 _91Qk1 <br /> /y, - <br />