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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 T 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 17 City Lot Size PM <br /> Owner's Name Address, <br /> Phone <br /> l <br /> E Contractor Address ense 1Vo. . Phone <br /> TYPE OF WELL/P MP; 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 AREACONSTRUCTION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca Dia. of.Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fi Public n Other ❑ Delta Depth of Grout Seal Type of Grout _" \ 1 <br /> I I Irrigation —--.Approxi Depth---[1-Eastern ­-Surface Seal Installed-by <br /> --- — — �V <br /> Repair Work Done ❑ Type of Pump H.P. State Work bane_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top ) r <br /> Depth Filler Material (Belo 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [I REPAIRlADDITION DESTRUCTION I 1 1No septic system permitted if public sewer is }•,� <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other <br /> i <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 lengthlsize <br /> FILTER BED ❑ Distance.to nearest: Wel' � n�d.wn Property Line <br /> i <br /> SEEPAGE PITS I I Depth ize Number <br /> SUMPS L7 Distance to nearest: Welloation Property Line <br /> D15POSAL PONDS r ❑' - -r <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: "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 ust ori requir pections. Campleta wing on reverse side. <br /> Signed X r} . Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted 6y Date 7-/ / Area <br /> Pit or Grout Inspection by Date Final Inspection byDate <br /> f 2 fid' <br /> Additional Comments: .=1 <br /> ❑ Stk '466-6781 y❑ Lodi 369-3621 ❑ Manteca x.823=7.104.., _-❑.Tracy--835-6385-: I <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P-0 -Box-2009 Stk., CA 95201 <br /> 1f. - <br /> 3 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> INFO CASH DATE PERMI- No. <br /> a EH 13-24IREV.tiKsi 7a 00 r7 �'�/ <br /> EH 13-24 - - ! dd <br /> ^-r <br />