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APPLICATION FOR PERMIT <br /> - SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <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 /> y <br /> / 1 <br /> Job Address City Lot Size PM. <br /> Owner's Name fress <br /> r� c <br /> � - 'Phone <br /> - <br /> Contractor Address Licens 6 No. Phone <br /> TYPE OF WELL/PUMIV NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION - l <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANC 0 NEAREST: SEPTIC TANK SEWER LINES <br /> OSA FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE W OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF ROBLEM CONSTRUCTION SPECIFICATIONS , <br /> ❑ Industrial ❑ Open Bottom me Dia. of Well Excavation Dia. of Well Casing <br /> 1A Domestic/Private E3Gravel Pa ❑ Tracy Type ing� Specifications <br /> 1-1Public 10r C1Delta Depth of Grout Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Wor ne ❑ Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth M ..Filler Material (Below-501-1 lam+! <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_ Other ; <br /> ill � # <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 w <br /> PKG. TREATMENT PLT. ❑ Method of Disposal f <br /> Distance to nearest: Well Foundation Property Line <br /> 4. <br /> LEACHING LINE ❑ No. & Length of lines Total lengdVsi. <br /> FILTER BED ❑ Distance to nearest: Well —FoundationW' Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth Size fi Number J <br /> SUMPS F1Distance to nearest: Well 4 p 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 r. <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 /> j tion laws of California." <br /> The appiican ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X R �� Q C-� Title: —Ly,, Date: <br /> r FOR DEPARTMENT USE ONLY L j <br /> Application Accepted by Date "`,v Area <br /> Pit or Grout inspection by Date . Final Inspection by <br />+ Additional Comments: <br /> C1 Stk 466-6781 ❑ L 369-3621 El 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 CASH RECEIVED BY DATE jPERMIT'NO. <br /> INFO+ EHM241REV.�/s5 / <br /> EH 1428 lll��� <br />