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APPLICATION FOR PERMIT <br /> v. <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Tele more (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is hereby made to the San Joaquin Local Health District for a pdrmit 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 * City 1-- X' Lot Size PM <br /> "i`- ' <br /> � QU/c- 1�/� .3 +C/Q /7 � Phone <br /> Owner's Name Address <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR PECIFICATIONS <br /> ❑ Industrial LJ Open Bottom El Manteca (Jia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'1 Public r Other ❑ Delta Depth of Grout Seal Type out <br /> I I Irrigation —.Approx. Depth i I Eastern Surface.Seai installed by <br /> Repair.Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter - Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l 1 DESTRUCTION (.No septic system permitted it 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 i <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Properiy Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll 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: "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 mus II r all re uired inspe ions. Complete drawing on reverse side. <br /> r <br /> Signed X Title: Date: <br /> FOR EPARTM NT USE ONLY <br /> Application Accepted by Date �� Area f / <br /> Pit or Grout Inspection by Date Final Inspection by ZLiLL­ Date ( .2.2 <br /> /y <br /> Additional Comments: /�, �~ � L-- <br /> ❑ Stk 466-6781 ❑ Lodi 369 ❑ Manteca 823 104 ❑ Tracy 835-6385 f <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk.,,CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVED BY DATE PERMIT'NO. <br /> a.EH 13-21(REV.I K 5) �j< 5 �C4 / \VVI <br /> EH 11-28 J / <br />