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APPLICATION FOR PERMIT nn <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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. 40-7- R— I-70 7 Z-,��o�'I� <br /> Job Address '5S � rc.bpbAIF, City L i Lot Size I ��: PM ` <br /> Owner's Name ��� AddressPhone <br /> Contractor L.F-E, W IA L.T)J)4 L-L Address J License No. ��a Phone do a <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 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION STRUCTION ❑ (No septic system permitted if public sewer is G <br /> available within 200 feet.) <br /> Installation will serve: Residence commercial— Other 6 <br /> Number of living units: --L— Number of JZedrooms <br /> Character of soil to a depth of 3 feet: � Water table depth <br /> SEPTIC TANK ❑ Type/M'-1.6— Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Wel Foundation Property Line <br /> LEACHING LINE E?-"No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to.nearest: Well Foundation Property Line_ NL <br /> SEEPAGE PITS m�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 /> ies 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 la of California. <br /> The applica st call fo all r uire i s tions,. mplete drawing on averse side. <br /> Si Title: Date: <br /> FOR DE RTMENT USE ONLY Application Accepted by Date < Area 7 <br /> Pitr Grout Inspection by v Date Final Inspection by -` '' ' Date` <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83541385 <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 H RECEIVED BY DATE PERMIT"N0. <br /> + EH 13-24 1REV.t/e5) <br /> EH 14-28 <br />