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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r , <br /> 1601 E. HAZEL T ON AVE.,,STOCKTON, CA <br /> MD r <br /> Telephone 52091 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> ! <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 ! City ��CC/ Lot Size ! '� Ply► <br /> / <br /> Owner's Name' / rG'J �7/� "i f^ Address _IY 2- J O `�` "'/?` w � Phone <br /> Contractor ��/ Address s ^tf 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. P t <br /> FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS �1 <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ra. of Well Excavation Dia. of Well Casing <br /> ❑ DomesticlPrivaie ❑ Gravel Pack y Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout"Seal Type of Grout <br /> ❑ Irrigation prox. Depth ❑ Eastern Surface Seal Installed by 111 <br /> Repair Wo ne ❑ Type of Pump H.P. State.Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50.1 4 JR <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> Y available within 200 feet.) y <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: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well foundationProperty Line <br /> LEACHING LINE ❑ No. & Length of lines r3 Total length/size <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 /> DISPOSAL PONDS ❑ .1 <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." F. <br /> icant must call for all r quired'inspections. Complete drawing on reverse side. <br /> Signed Title: Date:_ 4l/rPr ��i <br /> _ <br /> FOR DEPARTMENT USE ONLY <br /> I <br /> Application Accepted by Date � Area � <br /> Pit or Grout Inspection Date Final Inspection by jDate107 <br /> ' <br /> Y.� <br /> Additional Comments: ��-k�"` <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mantece 04 ❑.Tracy 835 fi385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.;Box 2009, Stk., CA 95201FEE ~~ <br /> R <br /> INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATES PE.RyMET NO. II <br /> + EH 3-24(REV. 5). �',.V � �/� !U / /.,_-y7 P7-111 <br /> 111 � <br /> EH 14-28 4J O <br />