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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> L + e 1eJ 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-Ml <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED m <br /> .:Y (Complete in Triplicate) 1 <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. •^ l ' <br /> Job Address City Lot Size- PM <br /> f� 1 <br /> Owner's Nam Address Phone <br /> I_ ? <br /> Contractor Address License No. PhoneIr <br /> s <br /> TYPE OF WELL/P P: NEWV WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 1 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ ` <br /> DISTANCE TON C TANK = SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION GRICULTURE WELL OTHER WELL TSTSUI �`_ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CTION SP ONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Di xci V 'Dia. of Well Casing <br /> Cl Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications <br /> ❑ Public ❑ Other r ., ❑ Delta . . Depth of Grout Seal Grout <br /> ❑ Irrigation pprox Depth •❑ Eastern - "Surface Seal Installed-by <br /> Repair Work Do Type of Pump H.P. State Work Done ._ <br /> Well D ction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> f 11 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUC I N INo eptic system permitted if public sewer is <br /> av 'able 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: Well Foundation Property Line �0 <br /> LEACHING LINE f ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation 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 employ persons subject to workman's compensa- <br /> tion laws of California." <br /> i The app t m t c fo�, uimd mplete drawing on reverse side. <br /> Signed Title: ��/� /w Date: / <br /> F(W DEPARTMENT USE ONLY <br /> Application Accepted by Date_�,. .___.� Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: #-106c) — ee4 W"e <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T acy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> INFO r9p� CASH (� <br /> + EH13-24(REV.i/e5) �S V" I -10 3 3­� - l <br /> EH 1426 <br /> f <br />