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APPLhCATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA TVOL +w.ty <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED NO <br /> L v <br /> (Complete in Triplicate) <br /> s <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 i <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. ��/1 i <br /> Cit Lot Size r ,O PM <br /> tl 1 <br /> Job Address Y <br /> r / r �/ <br /> Owner's Name ddress Phone <br /> 0441_ j f\/6-(_ <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER 171DISTANCE TO AREST: SEPTIC TANK SEWER LINES DJS.P AL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE T F WELL PROBLEM AREA CO RUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Botto ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack a Type of Casing Specifications <br /> ❑ Public F Other Delta Depth of Grout Seal' Type of Grout <br /> { I Irrigation _:_Approx. D I I Eastern urface Seal Installed by <br /> Repair Work Done ❑ Type of p H.P. State Work Done <br /> Well Destruction ❑ W.el iameter Sealing Material ftop 50 <br /> Depth Filler Material Ieelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I DESTRUCTIO ` (No septic system permitted if public sewer is <br /> available within 200 feet.) <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 I CJ <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line f1 <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <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 '^:❑ <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 /> w 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 applicant must call for a required inspections. Complete drawing on reverse side. J <br /> Signed X �' Title: ��" Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by % Date "U Area <br /> Pit or Grout Inspection by ' Date Final ction by � � Date !. <br /> Additional Comments: it <br /> -Pf�V1 fi�r <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED f3Y DATE PERMIT NO. <br /> INFO CASH [� <br /> a.EH 13-24(REV.1 5) <br /> EH 14-2a <br />