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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> II! <br /> t <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> I 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 /> J C2 ~t <br /> Job Address I S City M z` � t Size PM <br /> Owner's Name 2 I� �u f Address / B6r� S5�� i Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION B-*' SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TX6 SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATIION 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1`1 Public ❑ Other [ ❑ Delta Depth of Grout Seal Type of Grout __, <br /> I f Irrigation _.Apprax, Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ID Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth �' Filler Material 1Below 50') — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION €1 REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> I� 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 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> II <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED El Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1 l Depth IM Size Number <br /> SUMPS ❑ Distancelto 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 /> 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." Contractors 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 parsons subject to workman's compensa- <br /> tion laws of California." III t4: . <br /> The applican t call for all requi r ectio mplete drawing on reverse side. �i <br /> Signed X Tide:_On' 10 Date: ��� U �, <br /> I� R DEPAIUIENT USE ONLY <br /> 1011 <br /> A lication Accepted b Date raa <br /> PP P Y <br /> Pit or Grout Inspection by I�. Date Final Inspection by Dat <br /> Additional Comments: I� <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, Sik., CA 95201 <br /> FEE <br /> INFO AMOUNT DUET AMOUNT REMITTED CASH CK RECEIVED BY DATE p�PERMIT'NO. <br /> +.EH14-24{REV.riHsl U ll �- 1y7-45y�f <br /> EH 14-28 "l <br /> i <br />