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=5 <br /> 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 t Q <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 /> Loca�Health District. <br /> Job Address Jf �'� City - Lot Size PM <br /> / Owner's Name 41 VHNM,4 0 Addressf 6T Phone <br /> Contractor_ _ 1 � Address Oro 2 6,aA1- e IG(E License No. Phone r— <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAR EST: .SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> DATION AGRICULTURE WELL OTHER WELL PITS/ P <br /> INTENDED USE TYPE OF WELL M AREA CONSTRUCTION SPECI <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> 171 Public F1 Other Delta Depth of Grout Seal Type of Grout-- <br /> ­I I Irrigation Ap Depth I 1 Easternw� Surface Seal Installed by _ <br /> Repair Work Done ❑ T of Pump H.P. State Work,Done <br /> Well Destruction ❑ We eter Sealing Material Itop 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIRIADDITION i 1 DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.i <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 /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f'I Depth Size Number <br /> SUMPS I_1 Distance to nearest: Well Foundation Property Line c <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 /> t <br /> The applicant must call for all required inspections. Complete drawing on'reverse side. <br /> %Signed X Title: Data: v <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date L Y4irea } <br /> Pit or Grout Inspecti b Date Final Inspection by Date ` 5 <br /> Additional Comments: P2 PZI C e' 6,( <br /> t7 E� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95261 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 8Y DATE PERMIT NO. <br /> +.EH 13-24 1 REV.1/9 5) , 1 <br /> EH 14-28 <br />