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APPLICATION FOR PERMIT <br /> $ SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> �E <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 Ryles and Regulations of the San Joaquin <br /> Local Health District. Q /n� <br /> Job Address City Lot Size PM <br /> Owner's Name L i K t Address ✓ctn� Phone <br /> Contractor L atter Address PO 18a ( ff License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTAkE 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 J <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/ADWTION PIDESTRUCTION^No septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> Installation will serve: Residence V Commercial_ Other <br /> Number of living units: -- f <br /> � Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth' <br /> ILA <br /> SEPTIC TANK ❑ Type/Mfg GQ/ CapacityT3eZiO No. Compartments <br /> PKG. TREATMENT PLT. ❑ fi Method of�Dissposal <br /> Distance to nearest: Well_5b Foundation J D Property Line_SO <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well 4--b— Foundation 30/ Property Line _ <br /> SEEPAGE PITS ❑ 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 /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employlersons subject to workman's compensa- <br /> tion laws of California." _ <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> SignedX_ YJri�i�y <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by ���0�r Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date? V <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7194 ❑ 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 CK CASH RECEIVED BY C DATE PERMIT�`NO. <br /> + EH 13-24(REV.1/e s) 70,b, <br /> EH 14-26 l <br />