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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 1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED �. <br /> „ . 4 .. <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.TMs 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 i City _Lot Size - PM , <br /> Owner's Name IR - V., Address Phone 26223 <br /> ir <br /> Contractor's NameLicense No. -S 3 9 Phone <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 /> C] Public ❑ Other E) Delta Depth of Grout Seal Type of Grout_ <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by aYl <br /> Repair Work Done ❑ Type of Pump.goCT H.P. l State Work Done S <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material jBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ jNo 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 .? <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &'Length of lines Total length/sizes <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property tine C1 <br /> SEEPAGE PITS ❑ 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 /> 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: "l 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." <br /> The applicant mut til.for all reTIreq inspections. Complete drawing on reverse side. &5'Title: Dater <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Ue X <br /> Pit or Grout Inspection by Date Final Inspection by Date /�! i <br /> Additional Comments: <br /> ❑ Stk 466-6781 Er Lodi 369-3621 ❑ Aanteca 823-7 04 ❑-Tracy 835-6385 <br /> Applicant- Return ail copies to: Environmental Health Permit/Services 1661 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE NFO AMOUNT DUE' AMOUNT REMITTED. CA 0 RECEIVED BY DATE PERMIT"N0. ` <br /> +EH 13.24{REV.101831 <br /> EH 1448 p �dJ�� 'lS .�•. .,_ �i <br />