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APPLICATION FOR PERMIT 0 ~v <br /> SAN JOAQUIN LOCAL HEALTH DISTRI <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (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 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 /> E <br /> Job Address City JV& Lot Size -0 P2a PM d <br /> Owner's Name Address Phone <br /> Contractor 7� Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL R PLACEMENT ❑ DESTRUCTION ❑ J <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ r <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 CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing t <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing _ Specifications <br /> F1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> h 1 Irrigation -Approx, Depfh . I I Eastern Surface Seal Installed by _ <br /> f <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 501 f <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I 1 DESTRUCTION No septic system permitted if public sewer is ; <br /> —available-within 200 feet.l <br /> Installation will serve: Residence_—'Commercial_ Other •^- <br /> t r <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. Cornpartments' <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 Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS L7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONCES C1 r " <br /> 4 <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. r <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work fo�Awhich 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." Contractors 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 must call for all reqins ctions. Complete drawing on reverse side. y� <br /> r� <br /> }(Signed.X + Title: � Date: <br /> Cl.\ FOR DEPARTMENT USE ONLY <br /> Application Accepted by i - Date .2 Area <br /> Pit or Grout Inspection_ Date. ` Final Inspection by ate d <br /> Additional Commentd ` + �� �v1 ru ,Gy t <br /> .7 do-511- <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Ma teca 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 /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH13-34(REV.1/0 s) P7i <br /> EH 14-2er <br />