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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON AVE., STOCKTON, CA <br />Telephone (209) 466-6781 <br />PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />,(L (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 />Z• !� <br />Job Address I City Lot Size M <br />1 Of <br />/,L/.. <br />Owner's Name Address • a9 �3 Phone <br />C t i is Name eA4xLicense No. Phone <br />on roc o <br />TYPE OF WELL/'UMP: NEW WELL ❑ <br />PUMP'INSTALLATION ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK <br />FOUNDATION . <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />❑ Public <br />❑ Irrigation <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />SYSTEM REPAIR ❑ OTHER ❑ <br />SEWER LINES DISPOSAL FLD. PROP. LINE <br />AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Open. Bottom ❑ Manteca Dia. of Well Excavation <br />❑ Gravel Pack ❑ Tracy Type of Casing <br />❑ Other❑.Delta' tY Depth of Grout Seal <br />--Approx. Depih 0 Eastern �Yf' Surface Seal Installed by <br />Type of Pump H:P,:—'-" . State Work Done _ <br />Well Diameter Sealing Material (top 501 <br />Depth Filler Material (geln 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIONA DESTRUCTION ❑ iNo septic system permitted if public sewer is <br />available within 200 feet.) <br />Installation will serve: Residence !� Commercial OtherJy <br />Number of living units: I Number of bedrooms._ f <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. ❑ Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />k <br />Dia. of Well Casing <br />Specifications <br />Type of Grout— <br />LEACHING LINE No. & Length of lines 447 1r j Total length/size _ L <br />FILTER BED ❑ Distance to nearest: Well Foundation a144!! Property Line 4ec <br />SEEPAGE PITS <br />SUMPS <br />DISPOSAL PONDS <br />Depth 5 Size �_, Number <br />❑ Distance to nearest: Well 00 Foundation 0,41e– Property Line <br />n — ` <br />i6l <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 />j rules and regulations of the San Joaquin Local Health District. P - <br />f 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 taws of California." Contractors hiring or sub -contracting signature <br />certifies the following: '9 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." N .. <br />The applicant mus call for all required inspections. Complete drawing on reverse side. i <br />-� Title: Date: <br />Signed ; <br />PARTM j:NT USE ONLY <br />Date -,1� '��'O ! Area <br />Application Accepted.by i <br />Pit or Grout Inspection by <br />to D g Final Inspection by Date <br />Additional Comments. <br />❑ Stk 4664781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Servides 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />+ EH 13-24 [REV. <br />EH 1428 <br />