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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> b Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> s �s (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.ii rt ,r <br /> Job Address - w 1� fs YW°` City ISD Lot Size PM <br /> H Owner's Name `�� ` b P-r1 Address -e- ►S Phone <br /> Contractor-a��' 1 e 1N1"r Address 1 � �)S��►�.SS �G`� cense No Phone <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 SPECIFIC <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> � <br /> omestic/Private Ll Gravel Pack ❑ Tracy Type of Casing Se- / /'�Gl� Specifications <br /> Osv"O'C'" i <br /> (L] Public llfher � ❑ Delta Depth of Grout Seal c� Type of Grout <br /> ❑ Irrigation --.Approx. Depth ❑ Eastern Surface Seal Installed by CA <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 <br /> TYPE OF SEPTIC WORK:, NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if 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 '* CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance,to nearest: Well Foundation Property tine <br /> I <br /> LEACHING LINE ❑ No. & Length of lines Total length/size p <br /> FILTER BED ❑ Distance�to nearest: Well Foundation Property Line <br /> SEEPAGE PITS- ❑ Depth Size Number <br /> f. 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 /> f rules and regulations of the San Joaquin Local Health District. FJ <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 /> i employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signat <br /> I 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 applican ust call for requi ed!ins cti drawing on reverse ide. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 2-0 <br /> I. Pit or Grout Inspection by Date Final Inspection Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 486-6781 ❑ Lodi 369421 ❑ Manteca 823-7104 ❑ Tracy 83546385 <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 REMITTED GASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> 6 <br /> + EH 13-24IREV.5/651s.°�° . - I�Y ,� <br /> EH 1428 <br />