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0 APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE t ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> I <br /> PERMIT EXPIRES 1'YEAR FROM DATE ISSUED <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 /> Local Health District. p <br /> Job Address City Lot Size PM <br /> Owner's Name <br /> Address , Phone <br /> ''� ,� <br /> Contractor dress ��/� � license No.(r 8 0,y Phone v-92 <br /> TYPE OF WELL/PUMP: NEW WELL © WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE R LINESDISPOSAL.FLD. PROP. LINE <br /> FOUNDATION AGRI ULT URE W OTHER WELL PITS/SUMPS _ <br /> INTENDED USE - TYPE OF WELL PROBLEM ARA 956STRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open 9attom i7 A <br /> ia. of Well Excavation Die. of Well Casing <br /> 0 Domestic/Private ❑ Gravel Pack 17 ype of Casing Specifications <br /> ['1 public CI Other Cl epth of Grout Seal ' Type of.Grout <br /> I I Irrigation —..Approx. Depth I 1 urface Seal Installed byRepair Work Done ❑ Type of Pump State Work Done <br /> Well Destruction L1 Well Diameter Sealing Material [top 501 <br /> Depth Filler Material (U2w 50'1 --- <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I DESTRUCTION l 1 INo septic system permitted if public sewer is � <br /> / avail a�pithi 200 feet. <br /> Installation will serve: Residence�..-. Commercial— Other `}Vi 1*.1 <br /> Number of living units: Number of bedrooms <br /> O <br /> Character of sail to a depth of 3 feet: Water table depth <br /> i <br /> SEPTIC TANK ❑ Type/Mfg ap cit No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines 0 Total length/size <br /> FILTER BED ❑ Distance rest: _ Property Line <br /> SEEPAGE PITS I I Dep Size _ Number Z <br /> I SUMPS El Distance to nearest: WeII.r_4�_-Foundation.._J. _—'Property Line ' <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 thework 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 musPCall for all quired i pections. Complete drawing on reverse side. <br /> Signed X Title: Date: sK (! <br /> DEPARTESE ONLY <br />` C Date �' �'^ Area <br /> Application Accepted by <br /> I Pixar Grout Inspection by Date&K_ Final Inspection by Date <br /> I <br /> Additional Comments: <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. Bax 2009, Silk., CA 95201 <br /> FEE MOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. <br /> INF CASH <br /> + EM1321(REV.1 I"51 r <br /> j EH 11-24 �� C , l <br />