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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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 , % 76 So 1�1' il ( City-&Pyci1 66011 Size -PM <br /> �X Owner's Name codl , ress �NToN C1v Phone -,/ <br /> qc:fa y <br /> Contractor 04-0-kc-,! + 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 FLO PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �— WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mantgca—"""" Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack Q,"Tracy Type of Casing Specifications <br /> F1 Public Cl 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 Doae "L7 Type of Pump H.P. State Work Done_ if <br /> Well DesTfuuction ❑ Well Diameter Sealing Material (top 501 <br /> I-- Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I l REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if public sewer is <br /> vailable 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: WellFoundation Property Line U� <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 ❑ 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 DiMrict. <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, 1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The appli nt must call for required inspections. Complete drawing on reverse side. <br /> o•. L q <br /> Signed X Title: Date: A <br /> b 71 FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2A_ Area <br /> Pit or Grout Inspection by Date Final Inspection by �JrlLC ��_ 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 C SH RECEIVED BY DATE ///P���ERMIT`NO. <br /> + EH 13-241REV.tills) <br /> EH 14-28 ��-✓✓ �y "-t '�Ir �/ <br />