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APPLICATION FOR PERMIT <br /> 2,1 SAN JOAQUIN LOCAL HEALTH DISTRICT .� �LL� I <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 /> Job Address 7 4el r D S CityLot Size 5,Q) X /21 PM <br /> Owner's NameAddress 12- t� Phone <br /> Contractor Address 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 ER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NSTRUCT TIONS <br /> ❑ Industrial El Bottom ❑ Manteca . D' Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ a Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. ❑ Eastern Surface Seal Installed byRepair Work Done ❑ Type ofH.P. State Work Done W <br /> Well Destruction ❑ We iameter Sealing Material (top 501 p <br /> epth Filler Material (Below 501 _J <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 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 ❑ 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 must II or all require rspecti n . Complete drawing on reverse side. <br /> Signed Title: Date: <br /> R T.USE ONLY ^-_ <br /> Application Accepted byADate ���?VeArea <br /> Pit or Grout Inspection by Date Final Inspection by ��oto. , Date 1 <br /> Additional Comments: <br /> ,IrV.�3✓� - � Oh e- 13 r2_1 p <br /> t C_�. !Ptd- - c-54�y <br /> (1 l� _._.cis.—� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca-M-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH pRECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.X195) U U <br /> EH 144-28 �✓\ <br />