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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) 140`/1yL—_ <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 welupump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address 4 -7-c—L� L i7 - City Lot Siz PM <br /> Owner's Name dress Phone <br /> Contractor �►�L t Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK" SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO NST <br /> RUCTION SPECIFICATIONS <br /> ❑ Industrial Cl Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �a+ <br /> 1`1 Public 11 Other C1 Delta Depth of Grout Seal Type of Grout ��� <br /> I I Irrigation _-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ (( <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth I Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:{'NEW INSTALLATION l 1 REPAIRIADDITION l I DESTRUCTIO (No septic system permitted if public sewer is <br /> Ff. available within 200 feet.) \ <br /> Installation will serve: Residence'tt Commercial Other" <br /> Number of living units: Number of bedrooms <br /> Character of sail to a depth of 3 feet: Watentable depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity - No. Compartments <br /> PKG. TREATMENT PLT. 171 ;:I _ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line \ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth{ Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Cl <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. t <br /> I 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 /> k 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." f <br /> y <br /> The applicant mytt call for all requir d � pections. Complete drawing on reverse side. <br /> Signed X Title: l w J 6 Date: <br /> 4 FOR DEPARTMENT USE ONLY <br /> I Application Accepted by 1 Date Area <br /> s Pit or Grout Inspectio Data .Final Inspection by Lam! l�-�'it.t! � Date 0 <br /> i <br /> Additional Comments: :5-, 1;12: '7 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3 1 0 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 /> FEE AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.i/H s) <br /> EH 14-28 <br />