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4 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �.- <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ry <br /> Telephone (209) 466-6781 2 J —k, ? <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 Addresses CityCZ& _ Lot Size ff �® PM <br /> �1��y � <br /> Owner's NameSW„ �+ Address � 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 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL UMPS _ <br /> ___ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTCATIONS <br /> IO <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca o Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private" ❑ Gravel Pack Type of Casing Specifications <br /> ('1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —_.Approx. Depth I I Eastern Surface Seal Installed by _ , <br /> Repair Work D ❑ Type of Pump H.P. State Work Done_ <br /> Well uction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONI (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence A� Commercial_ Other �. <br /> Number of living units: Number of b6drooms <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 Ll 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 awto 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." Q <br /> (�h e applicarawing on reverse side. /gned XX _ Title: b�4 4&` �(4/ Date: /to—0� <br /> FOR DEPARTMENT USE ONLY f / <br /> Application Accepted by Date ` e L Q <br /> Pit or Grout Inspection Date Final Inspection by1'aCLe 7 J <br /> Additional Comments: o9- �� <br /> ❑ Stk 466-6781 ❑ Lodi 369-36il ❑ Manteca 823-7104 Vt 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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> + EH 13-24(REV. <br /> EH 14-28 <br />