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APPLICATION FOR PERMIT �/(� D C I 0 Sl <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL 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 /> I <br /> Job Address,I`l / % A�L City Lot Size PM <br /> Llc <br /> Owner' am / Address / Phone <br /> JA tz/ <br /> Contractor)\.T.(` �r�/�f^�--Addres§5 f Wd License 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 SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy. Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <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 _J j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION El (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: 1�_) Number of bedrooms <br /> Character of soil to a depth of 3 feet: t Water table depth IT <br /> SEPTIC TANK ❑ Type/Mfg C cam. /Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Diosal _ <br /> Distance to nearest: Well Foundation 140 Property Line_ <br /> LEACHING LINE ❑ No. & Length of lines >f` ." Total length/size <br /> 'moi <br /> FILTER BED ❑ Distance to nearest: Well 'CCiL-oundation Property Line <br /> SEEPAGE PITS E3Depth Size Number <br /> SUMPS ElDistance to nearest: Well Foundation Property Line)— <br /> DISPOSAL PONDS ❑ <br /> 1 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." <br /> The appli t4st I for all squired ins ions. Complete drawing ori reverse si .�J J <br /> Signed7FM Title: L ► ` Date: / �� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ��� Date !2 CP <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638<i <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> AMOUNT DUE AMOUNT REMITTED TED CASH RECEIVED BY DATEfPPERMI/T'NN/O. <br /> + EH 13-24(REV.1/e 5) 1 0 <br /> EH 14.28 t Q V Q O <br />