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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA C <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 /> Job Address os,_3 2 / City Lot Size PM <br /> 01 <br /> Owner's Name : G/C$027 Address ­(�71"P �- Phone <br /> Contractor 4&iG 6'ft-7 Address _ 536 fl. 'Arse a License No.3*/0/40 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 ( ,t <br /> FOUNDATION AGRICULTURE WELL OTHER WE TS/SUMPS (y'U <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUC ECIFICATIONS VC�� <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Welt-Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel, Pa�I, E] Type of Casing Specifications <br /> i'1 Public n Other Depth of Grout Seal Type of GroutI I Irrigation __.Ap Surface Seal Installed by <br /> Repair Work Done U e of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> lnstallation`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. ❑ 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 I I Depth Size Number <br /> 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 /> 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 applicant ust call for all required inspe ions. Complete drawing on reverse side. - <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY o' <br /> Application Accepted by Date1"Zd a I� Area <br /> Pit or Grout Inspection by ` Date Final Inspection by .0,��.L.�� Date 1 <br /> Additional Comments: c) <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 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 /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13.24(REV.I/N5) 3� �J-(� �p,+ ` /' . M <br /> EH 14-M 1`-1 V /C r J 1 (.J <br />