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t APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 'AVE., STOCKTON, CA <br /> E f1' Telephone (209) 466-6781. <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br />'p Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein ascribed. 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. 7 <br /> Job Address go ZI f �] City of Size PM <br /> Owner's Name Address o'er acre Phone —es-2—O d. <br /> Contractor `. a,n Address—$ <br /> License No. Phone J47'r 00i <br /> TYPE OF L UMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 <br /> ❑'Domestic/Private„ O Gravel Pack 0 Tracy Type of Casing Specifications <br /> M Public ❑^Other n Delta Depth of Grout Seal Type of Grout _ <br /> I I lsrigation _Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'1 REPAIR/ADDITION I I DESTRUCTION l I Wo 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 <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 I'l Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line ti <br /> DISPOSAL PONDS ❑ <br /> 1 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, f 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 c I for all required inspections. Complete drawing on reverse side, <br /> )(Signed X Title: Date: SZg Z? <br /> R DEPARTMENT USE ONLY <br /> Application Accepted by Y� M1 pate �– Area <br /> Pit or Grout Inspection by Date Final Inspection by Date Q <br /> ']�_ <br /> Additional Comments: 6 CP <br /> ❑ Stk 466-6781 ❑ Lodi 3694621 ❑ Manteca 823-7104 ❑ rk y" 83 -6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INF AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> +,EH 13-2�TREY.1/n51 <br /> ` EH U^2d W U <br />