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APPLICATION FOR PERMIT } <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA l <br /> -Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED .k <br /> (Complete in Triplicate)., k <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 5 City -+© Lot Sizers PM <br /> Owner's Name - Address Phone 1 x <br /> .i, � kr <br /> Contractor Address !I...j L CrP,y­ $ License No. (/6Phone <br /> t <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 /> i " <br /> # FOUNDATION 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 Well Casing <br /> [,'Domestic/Private 0 Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Public ❑ Other- ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---,Approx. Depth ❑ Eastern Surfce Seal Installed by <br /> E Repair Work Done ( Type of'Pump �S H.P. _ �—F - State Work Done f <br /> Well Destruction ❑ Well Diameter �Y Sealing-Material It up-501_ r <br /> Depth ` ' Filler Material IBelow 50') <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: Residence Commercial_I Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: `�' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well"""`" 'c" Foundation _Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size I <br /> FILTER BED ❑: Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth., Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation ' Property Line <br /> ai <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. <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 nota <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify thit 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 /> Thea mus all for all re dins tions. mplete drawing verse side. <br /> r , <br /> Signed X ✓ Title: Date: <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date_����•��� Area <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835:6385 <br /> r <br /> Applicant- Return all co res to: Environmental Health Permit/Services 1.601-E..Hazelton Ave., P:O:,Box 2009; Stk:,.CA 95201x• . <br /> i FEE AMOUNT DUE AMOUNTREMITTED" a-CK, RECEIVED BY DATE PERMIT NO. <br /> l INFO CASH <br /> + EH 1324{REv.Iins1 <br /> E.14-28 <br />