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� nn APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> e <br /> Job Address Ck <br /> � 4ee� �/ City Lot Size �Lf PM <br /> �a <br /> Owner's Name IS-C / �.�A Address Y' /ILS( Phone <br /> Contractor Address l dt!t��tLicense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL-N, WELL REPLACEMENr ❑ 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 SPECIFICATION <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private j Gravel Pack ❑ Tracy Type of Casing J-C r Specifications <br /> M Public ❑ Other ❑ Delta Depth of Grout SealType If Grout <br /> I I Irrigation oZ Approx. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work done <br /> Well Destruction ❑ Well Diameter s Sealing Material (top 501 <br /> Depth d1.6 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IJ REPAIR/ADDITION I 1 DESTRUCTION I I (No septic system permitted if public sewer is <br /> avalevithin200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other y } <br /> Number of living units: Number of bedrooms `J <br /> Character of soil to a depth of 3 feet: Water tabfe depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity NO °Compartments 1 <br /> PKG. TREATMENT PLT. ❑ Method of„D4ps*1, `-`°0t <br /> Distance to nearest: Well Foundation Pre <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, <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, 1 shall not <br /> employ any person in su nner as to become subject to workman's compensation laws of California.”Contractor's hiring or sub-contracting signature <br /> certifies the following: ' ify that in the performance of the work for which this permit is issued,1 shall employ persons subject to workman's compensa- <br /> tion laws of Californi .' <br /> The applicant mus r II r r inspections. Complete drawing on reverse si <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �_ —U" Area <br /> Pit or Grout Inspection by DateFinal Inspection by Date <br /> Additional Comments: <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 INFO AMOUNT DUE AMOUNT REMITTED CKf CASH RECEIVED BY DATE PERMIT N0. <br /> + EH 13-24(REV.I/H 5) <br /> EH 14-28 it c�s <br />