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APPLICATION FOR PERMIT <br /> SAN JOAQUiN'LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL*TON AVE.,gSTOCKTON,.CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES-1 YEAR'FROM DATE ISSUED <br /> (Cbniplete in Triplicate) <br /> Application is herebymade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made H compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for weil/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District. i�r,.., r r <br /> rl11am2��rrtZ. �" .-f;• ', t •a1s,� <br /> Job Address ` <br /> w CityY .,:. <br /> Lot Size PM <br /> Owner's Name Address ZZ 3� C <br /> ���`��'+ �Phone -- - <br /> Contractor S�A(I�dress .ZarrTYPE OF WELL/PUMP: 'License No. a`L ��✓� PhoneMEW WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Cl SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANKOTHER ❑ <br /> SEWER LINES -�� OTHER WEDILLSPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL i <br /> PITS/SUMPS: <br /> ❑ , <br /> INTENDED USE TYPE OF WELL f PROBLEM AREA CONSTRUCTION SPECIFICATIONS - <br /> Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation <br /> C1 <br /> Domestic/Private Gravel Pack ❑ Trac Dia. of Well Casing <br /> CI Public Y Type of Casing Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> r&h 70-XIrrigation ---Approx. Depth ❑ EasternType of Grout <br /> Repair Work Done EJ Type of Pump H.P. <br /> P Surtace Seal Installed by <br /> State Work Done � <br /> Well Destruction ❑ Well Diameter <br /> - Sealing Material(top 501) 0 <br /> Depth Filler Material (Below 501) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ RE PAI VA DDI Flo ❑ DESTRUCTION L3 (No septic system permitted if public sewer is <br /> Installation will serve:. Residenceavailable within 200 feet.) <br /> Commercial_ Other <br /> Number of living units: Number of.bedrooms <br /> Character of soil to a depth of 3 feet: t s <br /> SEPTIC TANK ❑ Type/Mfg Water table depth PKG. TREATMENT PLT. ElCapacity- No. Compartments . <br /> Distance to nearest: WellMethod of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines �. <br /> Total length/size <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line r <br /> SEEPAGE PITS ❑ Depth :r <br /> Size Number <br /> SUMPS Cl Distance to nearest: Well r <br /> DISPOSAL PONDS ❑ Foundation ` Property Line <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 person in such manner as to 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 appli n ust call for all r ed ins ; <br /> pe ions. C let drawing on reverse side. <br /> Signed <br /> Date: <br /> F R DEPARTMENT USE ONLY <br /> Application Accepted by * ~1 <br /> Date I <br /> - <br /> Pit or Grout Inspection by - Date Final lnspectio Area <br /> '` <br /> Additional Comments: Date_ 2`f' <br /> ❑ Stk 466-6781 <br /> ❑ Lodi 369-3621 El Manteca 823-7104 ID Tracy 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE' AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 1 -241REV.1/851 <br /> EH 1426 , <br />