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i <br /> APPLICATION FOR PERMIT AYMS Dom~ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT P��r � <br /> 1601 E. HAZELTON AVE., STOCKTON, CA R <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) Nv�RQNM. SR�JK�S <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work erein?fM 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 City Lot Size PM <br /> Owner's Name/ T Address / 5 ��� �.rPhone <br /> �j <br /> Contractor Address s License No. Phone <br /> TYPE OF WELL/PUMP: r NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 t <br /> PUMP INSTALLATION *-' - SYSTEM REPAIR '❑ OTHER ❑ <br /> DISTANCE TO NEAREST::SEPTIC°.TANK:' SEWER LINES - DISPOSAL-FLD. P-ROP..LINE - <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Ind trial ❑ Open Bottom LI Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ;;_1_.estic/Private ❑ Gravel Pack CR<cy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Dept.Y 9 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump' s H.P. State Work Done <br /> Well Destruction ❑ Well Diameter,: Sealing Material (top 501 <br /> s <br /> Depth Filler Material (Below 501 t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION L1 DESTRUCTION ❑ (No septic system permitted if public sewer is 1 <br /> 4I, available within 200 feet.h # <br /> Installation will serve: Residence_ Commercial— Other `� e <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 l <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property'Line <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 /> I` 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 /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> - 7-2/1 <br /> Signed Title: Date: 7 <br /> �A F R DEPARTMENT USE ONLY <br /> Application Accepted by v'� Date T 7`rif- <br /> r <br /> Pit or Grout Inspection by Date Final Inspection by Dai j <br /> i <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 /> I _ , <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# RECEIVED BY DATE PERMIT NO. <br /> INFO f�CASH <br /> + EH <br /> EH 14-26 <br /> 13.24MEV.1/65) 3S <br />