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APPLICATION FOR PERMIT <br /> $ i*= <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> ! 1601 E. HAZE`TON AVE., STOCKTON, CA <br /> SAN JO QUI N LOCA. Telephone (209) 466-6781 <br /> HEA'®T DISTRICT PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I. <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 /> Jab Address Ci Lot S r--- PM <br /> Owner's Name Phone �`S! <br /> s <br /> w J <br /> Contractor's Name License No((, '2 3 7 3 Phony <br /> TYPE OF WELL/PUMP: NEW WELL Q/ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION a SYSTEM REP)IR ElOTHER 1:1 <br /> DISTANCE TO NEAREST: SEPTIC TANK _ � SEWER LINES d® DISPOSAL FLD_ PROP. LINE lP <br /> FOUNDATION* 61 AGRICULTURE"WELL-.' - OTHER-WELL-__T-0--' -PITS/- SUMPS-����+ U. <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex c n Dia. of Well Casing <br /> ❑ Domestic/Private lvdravel Pack ElTracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal ' Type of Grout <br /> "-❑ Irrigation a -. Approx. De�ptP ' Eastern Surface Seal Installed by <br /> -•- Repair Work_Done_;j Q-;:Type_ofmP_ump -r_....H.P, - -State-Work-Done <br /> 9 <br /> Well-Oe ucticn ❑ Well Diameter Sealing Material (top 501 { <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public seweris <br /> f, 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 <br /> PKG, TREATMENT PLT. ❑ I Method of Disposal <br /> Distance to nearest: Well - Foundation Property-Line <br /> LEACHING LINE ❑ No. & Length of fines Total.length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation {Property Line y <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ r �" <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." i <br /> The applicant u cal r all re uir inspections. omplete drawing on reverse side. ; <br /> Signed 1 isle: Date: 4" <br /> 1 <br /> / � FOR DEPART ENT USE ONLY <br /> Application Accepted by IN Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by Date { <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -823-7104 ❑ Tracy 835-6385 s <br /> Applicant- Return all copies to: Environmental Health PermiUServices 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE ;AMOUNT REMITTED CK# RECEIVED BY DATE f?ERMIT­NO.'INFO CASH <br /> WA <br /> t EH 13-24(REV.10/831 �� <br /> EH 14.28 <br />