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., APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT :{ <br /> 1601 E. HAZE T ON 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 /> f Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name <br /> Address s <br /> Phone -�/ <br /> Contractor Jed/ �Address.��/� Zor,License No OOO 3 or+n // <br /> Phan /( <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 r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom d Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack LI Tracy Type of Casing - <br /> Specifications <br /> r- Public F Other fl Delta Depth of Grout Seal <br /> I 1-Irrigation --Approx. Depth l Eastern Surface Seal Installed Type of Grout by \n <br /> Repair Work Done ❑ Type of Pump H.P. State Work pone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 ` <br /> Depth ' Filler Material (Below 50') s� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION DESTRUCTION 1.1 (No septic system permitted if public sewer is <br /> avaiiable'within 200 feet.) t <br /> Installation will serve: Res encu Commercial-- Other <br /> Number.of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ` / <br /> Water table depth <br /> ` <br /> SEPTIC TANK ''`� Type/Mfg <br /> P Y <br /> PKG. TREATMENT PLT, ElNo. Compartments <br /> Method of Disposai�. <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINEf <br /> Jf'No. 8 Length of lines. Total length/size 970 <br /> FILTER BED ❑ Distance to nearest: Well B t Foundation d 'ice <br /> -� Property Line <br /> SEEPAGE PITS ! IDepth Size Number <br /> SUMPS ❑ Distancetonearest: 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 gent's signature certifies the following: "1 certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in s h ' nner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the following: I rtify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's cgmpensa- <br /> tion laws of Californi .' <br /> The applica us I for all ired i ons omple drawing on reverse side <br /> Signed Title: <br /> Date: <br /> FO EPARTMENT USE ONLY <br /> Application Accepted by DateA "7 <br /> rea _ <br /> Pit or Grout Inspection by DateFinal Inspection by f� <br /> Date* <br /> _ pec / <br /> Additional Comments: <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 RE ITTED CK <br /> INFO CASH RECEIVED B DATE aPERMITNC,EH 13-24(REV.if�14-26 r vv �(�/7 <br />