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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON dAVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) ' <br /> Y - <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. a <br /> Job Address / Z 3-'r . City 21 Lot Size o-c—rP—, PM <br /> Owner's Name D 90 MTAddress Phonel3a 11 <br /> Contractor &ag Ilk Address License N "7 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 `r 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well'Diameter Sealing Material itop 501 <br /> �T Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION b< DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence r Commercial_ Other <br /> Number of living units:� Number of bedrooms a <br /> I <br /> Character of soil to a depth of 3 feet: 4Water table depth <br /> SEPTIC TANK ❑ Type/Mfg' Capaci y No. Compartments <br /> PKG. TREATMENT PLT. ❑--- Method of Disposal <br /> -Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE t � No. & Length of lines � - � Total length/size_. dti X]�f <br /> FILTER BED j ❑ Distance to nearest: Well �a���_ Foundation 10 Property Line <br /> SEEPAGE PITS ❑ Depth Size Number " <br /> SUMPS <br /> M <br /> ❑ Distance to nearest: Well Foundation Property Line I <br /> DISPOSAL PONDS ❑ �_ y <br /> 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 j <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, (shall employ persons subject to workman's compensa <br /> tion laws of California." <br /> The applicant m t call for all equ' J rispe'io s. Complete drawing on re' a ste. <br /> Signed Title: Date: 1,6 <br /> eelFOR DEPARTMENT USE ONLY <br /> Application Accepted by � � �— Date ID le?5A rea <br /> Pit or Grout Inspection by Date Final Inspection by _ Date <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 /> INFO AMOUNT DUE AMOUNT.REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> + <br /> EH' <br /> 3-241REV.i/a57 <br /> EH 14-26 S • O <br />