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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 /> Job Address 9 City Q" Lot Size PM <br /> Owner's Name ��� .� f� Address{(5,0`1 9 1 i 4. \J�iL�.�1TT�"� Phone <br /> Q / r <br /> Contractor Address f L/ [?'X�1a7 ( License No. zZ Phone SPU- 10� <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 /> 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public ❑ Other {-1 Delta Depth of Grout Seal Type of Grout <br /> I 1 Irrigation —Approx. Depth f I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction 0 Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I I DESTRUCTION I I (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: <br /> Number of 07drooms <br /> Character of soil to a depth of 3 feet: Water table depth too <br /> SEPTIC TANK U41"Type/Mfg Capacity /0?00 No. Compartments Ig <br /> PKG. TREATMENT PLT. ❑ f r f Method of Disposal <br /> Distance to nearest: Well 5 Foundation—O Property Line <br /> t ' <br /> LEACHING LINE No. & Length of lines L—<28 � Tor tal length/size X <br /> � <br /> FILTER BED ❑ Distance to nearest: Well�� Foundation_ 10 Property Line <br /> SEEPAGE PITS Ik Depth Size LIF Number <br /> SUMPS 0 Distance to nearest: Well Foundation 10 .._..-.` Property Line __ <br /> DISPOSAL PONDS ❑ <br /> 1 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 /> iion laws of California." <br /> The applicant ust calf for requ-ed inspections. Complete drawing on reverse id 0 Q 7 <br /> Signed X Title: � � Date: f� <br /> FOR ID ARTMENT USE ONLY <br /> �Plp) <br /> ication Accepted by ' Date f , Area ._ _!Z <br /> r Grout Inspection by Rate 'r Final Inspection by Date ZZ, :G <br /> Additional Comments: <br /> ❑ Stk 466-6781 0 Lodi 369-3621 0 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201 <br /> INFO AN(OUNT DUE AMOUNT REMITTED CASHFEE CK RECEIVED BY DATE PERMIT NO. <br /> + EH13-24(11EV.v/N5) 112—F­P7 <br /> EH 14 29 <br />