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APPLICATION FOR PERMIT /le <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT N� <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 /> /or install the work <br /> n describe . This <br /> cation is <br /> madle in conmpliance with SanoJoaqu nthe SanCoungty Ordinance Joauin lHealth District for a No.549 for sewage or't to No 1862 forcwell/dpump and the Rules and'Regulations of the San Joaquin <br /> Local Health District. ,y l <br /> 'Z// Z 4 <br /> S. 4-4 Sl. City sem^ Lot Size PM <br /> Job Address <br /> Owner's Name r'© d'7 <br /> y r D>111e_ Address S'a.s+y� Phone Y6 <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/ P: NEW WELL ❑ WELL REPLACEMENT ❑ D RUCTION ❑ \ <br /> P INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ \ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES POSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR NST CTION SPECIFICATIONS <br /> [I Industrial El Open Bottom El Manteca Di . of cavation Dia. of Well Casing <br /> ' ❑ Domestic/Private El Gravel Pack El Tracy Type of Casing Specifications <br /> Depth of Grout Seal Type of Grout <br /> n Public L1 Other ❑ Delta — <br /> J <br /> I I Irrigation _.Approx. Depth l I E ern Surface Seal Installed by- <br /> 1 <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diamete Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION l I DESTRUCTION (No septic system <br /> m permitted if public sewer is <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 /> i. <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 L1 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 call for all re inspections. Complete drawing on reverse side. <br /> Signed X <br /> �y�--- Title: Date: <br /> FOR DEPARTMENT USE ONLY fid <br /> Application Accepted by Date � �/ Area <br /> L 412 <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: ` ° G �0 �x~ / <br /> i <br /> ❑ Stk 466-6781 ❑ Lodi -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 /> CK I <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE Q PERMIT/NO. <br /> INFO <br /> + EH 13-24(REV.t/x 5) <br /> EH 14-26 <br />