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` APPLICATION,FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6* <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED . r <br /> .(Complete in Triplicate) is <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 Regulation's of the`$ari Joaquin <br /> Local Health District. <br /> Job Address :n �" r! City Lot Size r PM <br /> Owners Name _L� u AddressJ,?42 7 St ,Q� � �f Ph.o.._5 <br /> C <br /> Contracto - Address Z) /� <br /> License IVa. � "� Phvn r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ C� <br /> PUMP INSTALLATION Ok, 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 r <br /> LKDomestic/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 /> s <br /> Repair Work.Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter 5e61i g aterial'(top 50`) <br /> Depth �;, *,Filler-Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ .REPAIWADD(ITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial--- Other <br /> Number of living units: Number of bedrooms 1 T p <br /> Character of soil to a depth of 3 feet: .- t Water table depth <br /> SEPTIC TANK ❑ T e/Mf a . <br /> YP 9 Capacity _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ - + 4 Method of Disposal ., <br /> Distance to nearest: Well } +Foundation Property Line <br /> P, <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 3 <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 fog 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 ail required inspections. Complete drawing on reverse side. <br /> Signed X Title; <br /> Date: 13_122- <br /> OR <br /> Z <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by f ' "z r Date f Area ! <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca_ 823-7104 ❑-Tracy 835-6365 <br /> Applicant - Return all copies.to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED GASH RECEIVED BY DATE PERMIT ND. <br /> + EH 13-24(REV. <br /> EH 14-26 <br />