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APPLICATION FOR PERMIT ESS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> ? PERMIT EXPIRES VYEAR FROM DATE ISSUED <br /> V (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 /> I i <br /> _Op r4 — City 15L/ 4) _ Lot Size PM <br /> Job Address /y <br /> Owner's Name of f ►�/ j Z Address Phone <br /> Address �K 7" License No2� Phone <br /> Contractor P <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK `SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> LI Domestic/Private L] Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'] Public Ll Other F1 Delta Depth of Grout Seal Type of Grout <br /> --- <br /> I l Irrigation --Approx. Depth I I Eastern Surface Seal installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> S <br /> Well Destruction ❑ Well Diameter Sealing Material flop 50'1 <br /> i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION { I REPAIR/ADDITION i l DESTRUCTION I (No septic system permitted if public sewer is <br /> available within 200 feet.I <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 <br /> PKG. TREATMENT PLT. ❑ � - '7- "~` 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 r Foundation Property Line <br /> II SEEPAGE PITS I 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, slate laws, and <br /> rules and regulations of the San Joaquin Local Health District. I <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 s ch manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the fol 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 fif n <br /> The applican or all required inspections. Complete drawing on reverse side. e <br /> Signed X Title: <br /> Date: O J 0 <br /> FOR DEPAR'T'MENT USE ONLY <br /> Application Accepted by <br /> Date V ' 1 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date` / <br /> ditional 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 /> FEE AMOUNT DUE AMOUNT REMITTEDaE <br /> RECEIVED BY DATE PERMIT N0. <br /> INFO <br /> 1 + EH 13-24 1REV.1 sl �� <br /> EH 14-26 <br />