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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <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! um <br /> 9 p p and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> r <br /> Job Address7fZO &5Z City� � � Lot Size PM <br /> Owner's Name Address d Phone <br /> Contractor Address -7.S� G License No. 'C2 '4Z Phone AW `-'� <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 <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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r'l Public i_l Other ❑ Delta Depth of Grout Seal Type of Grout­ <br /> I I Irrigation --Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Seating Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION�ki REPAIR/ADDITION I I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence <br /> (NC —..._Yther <br /> Number of living units: Number of bedroo <br /> O I <br /> Character of soil to a depth of 3 feet: � �7- G C-%— Water table depth - <br /> SEPTIC TANK ❑ Type/Mfg L_ Capacity eO No. Compartments Z // <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �7 <br /> Distance to nearest: Well Foundation Property Line I <br /> LEACHING LINE No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS C 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, j-� <br /> rules and regulations of the San Joaquin local Health D�trict. <br /> Home owner or licensed agent's signature certifies the following: I certify that in the <br /> � Y 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."Contractors 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." ;t <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: <br /> Data: <br /> FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by Date Ar a y <br /> Pit or Grout Inspection by Date Final Inspection by Date `�� <br /> Additional Comments: I <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 I <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hiielton Ave., P,O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO ss ` CASH RECEIVED BY DATE ((yyPERMIT'NO. <br /> +.EH13-211REV.tin51 7V -6(/ �fo. pJ 131U `�_z�-Q� 0y,'1J_3I ! <br /> EH 11-28 "' �I Qd[1P <br />