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, <br /> APPLICATION FOR PERMIT <br /> �i SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA CIVS <br /> y <br /> Telephone (209) 466-6781. <br /> PERMIT EXPIRES 1"YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application.'is heieby 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 with San Joaquin County Ordinance No. 549 for sewage or No. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �'T$ !� r City Lot Size Av'X./ST PM <br /> Owner's Name Q Address Phone <br /> Contractor Address b License No. ��6 Phone�4"-POSNO <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION Ll SYSTEM REPAIR ❑. OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK S WER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG CULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR CONSTR TION SPECIFICATIONS " <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. ell Excavation Dia. of Well Casing <br /> t <br /> ❑ Domestic/Private ❑ Grael Pack ❑ Tracy T of Casing Specifications <br /> M Public l� Other } C Delta epth o out Seal Type of Grout <br /> -—­ <br /> I t Irrigation Approx. Depth 1.1 Eastern Surface Seal In lied by <br /> Repair Work Dane ❑ Type of Pump ' H. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'I C <br /> Depth= Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION I ] DESTRUCTION 1Na septic system permitted if public sewer is <br /> Installation will serve: Residence, Commercial_ Other vail able within 200 feet.) <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 9 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 I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line i <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 Di§trict. <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 lifornia." <br /> The appfic t ust cal or all required ins tions. Complete drawing on reverse side. <br /> Signed X "Title: � <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: -7 <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 CK RECEIVED BY <br /> INFO CASH DATE I�JPERMIT"NO. <br /> +.EH 13-21(HEV.1/K si <br /> 11-28 �Y"OY b��J ` /� 6s <br /> EH <br />