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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 /> .i <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED yl <br /> I <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..,,, <br /> Job Address 3 YQ A)(E- ► 1 d City r I 101- <br /> 0 Lot Size PM <br /> Owner's Name 1/ A U 1 j-1 i! Address /2 3 O Phone /f I <br /> Contractor's Name 0 JJ N 991 1 S 1_1 _323License No. ,2 Zr _ Phone 'V <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> V <br /> DISTA/NCE 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 ---0-Manteca- -r---Dia-of-Well-Excavation- - - -- ..-.Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ 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') <br /> Depth -Filler-Material(Below-501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> vailable within 200 feet.h <br /> Installation will serve: Residence Commercial_ Other"" <br /> Number of living units: Numb r of bedrooms <br /> Character of soil to a d,,pt of 3 feet: - Water table depth <br /> SEPTIC TANKType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PL ❑ 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest:' Well Foundation'" Property Line-1 <br /> DISPOSAL PONDS ❑ i <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 Califor <br /> The applicant st call or all requ' nspect ns. Co ete drawing on reverse side ' <br /> Signed �� Title: �-� [r'f, / Date: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> _ i <br /> Application Accepted by ,�-fir- Date �� 0 4r Area <br /> i <br /> Pit or Grout Inspection by Date Final gpection 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. Box 2009, Stk., CA 95201 <br /> I <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY ATE PERMIT'NO. <br /> +EH 1241REV.10183) <br /> EH 144.26 <br />