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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 <br /> 3 <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA lid C��' <br /> a Telephone 1209i 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED KMAR <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 hereinHEALTH <br /> a �4 r <br /> j made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulal-ER�?lt►�ey,LF�±i� <br /> Local Health Dist <br /> ric <br /> - <br /> t. <br /> Job Address f`7� City Lot Size PM <br /> Owner's Name Address 457 ca -ST � y Phone <br /> Contractor c ddress O License <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ { �' <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE "t1 <br /> - FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C' <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public [1 Other ❑ Delta Depth of Grout Seal Type of Grout _. <br /> I I Irrigation —_Approx. Depth I 1 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 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION l 1 DESTRUCTION I I Wo septic system permitted if public sewer is <br /> Installation will serve: Residence_ Commercial_ Other available within 200 feet.I <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 tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS f I 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 /> The applicant nNst call for all required inspections. Complete drawing on reverse side. <br /> Signed �1 � Title Date: <br /> ART NT USE ONLY <br /> Application Accepted by Dat-3— 1 Area <br /> Pit or Grout Inspection by <br /> Additional Comments: Date Final Inspection b Date 1 O� <br /> i <br /> � <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 AMOUNT DUE AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMI7'No.. <br /> 5� �J <br /> + EH 13.24 tttEV.1/M 51 ! / <br /> EH 14-28 / <br />