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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 /> sw (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. 1662 tot well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address I �.�r/ �/Y ' rD� � City '`�f <br /> tot Size PM <br /> Jinte,'s Name r Address �� l��UPhone <br /> n <br /> Address License No. Phone <br /> ractor <br /> TYPE OF WELL/PUMP: NE WELL ❑ WELL R LACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR 11 OTHER ❑ ; <br /> DISTANCE TO NEAREST:. SEPTIC TANK SEWER LINES DISPOSAL FLD, PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation t Dia. of Well Casing <br /> mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public 171 Other Cl Delta Depth of Grout Seal i Type of Grout _ W <br /> I I Irrigation _Approx. Depth 4 I Eastern rface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [ I REPAIR/ADDITION [I DESTRUCTION l I (No septic system permitted if public sewer is i <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other `\ I <br /> Number of living units: Number of bedrooms (� ' <br /> Character of soil to a depth of 3 feet: Water table depth 1 <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments �± <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> 'Distance to nearest: Well Foundation property Line I <br /> a <br /> Vi <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED '❑ Distance to pearest: Well Foundation Property Line (� <br /> ' t <br /> SEEPAGE PITS 1 I 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 /> this h ermit is issued I shalt not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which c p <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 fol wi g: "I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workm n's co ansa <br /> E tion laws oNnfo nia." <br /> The applicc I all re ed i ctions. Complete drawing on reverse <br /> Signed X <br /> Tide: /�L d Date: G(/ <br /> FOR DEPARTMENT USE ONLY <br /> Ii Application Accepted by Date Area 1 <br /> Pit or Grout Inspection byDate f=inal Inspection by �'1 c _ Date fe— �� <br /> Additional Comments: <br /> ❑ Stk 466-6781 LJLodi 369-3621 ❑ Manteca 823-7104 13Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 1 FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED ASR RECEIVED BY DATE PERMIT NO. <br /> r.EH 13-24 IREV.I/H 51 Zl/,/ —Aw <br /> EH 14-2a <br />