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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT V <br /> 11A 1601 E. HAZEL T ON AVE., STOCKTON, CA paw <br /> j Telephone (209) 466-6781 J <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. <br /> Job Address " �1 '� City. Lot Size PM <br /> � Owner's Name <br /> W �% j , — Address l / l.� ��/��C +✓��� ✓� Phone t <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMPU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEMREPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUNDAT AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL OBLEM AREA COMISTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation Dia. of"Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack /❑ Tracy Type of Casing Specifications <br /> FI Public ❑ Other ❑ Delta h of Grout Seal Type of Grout — <br /> I I Irrigation Approx. Depth I I Eastern Surface Installed by <br /> Repair Work Dofi—e-0 Type of Pump H.P. to Work Done_ VA <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION ( I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK X 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 lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 must call for all Iequired inspections. Complete drawing on reverse side. d / <br /> Signed Xs `- i Title: Date: <br /> Date: (� � � <br /> O FOR DEPARTMENT USE ONLY <br /> Application Accepted b '*,,\ <br /> %-,' Date —� Area O <br /> Pit or Grout Inspection by Date ��� <br /> Final Inspection by Dat <br /> Additional Comme"nt3:VW71,W22Wt / <br /> ❑ Stk 466-6781 ❑ Lddi 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H" RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.1/8 5) lb­c7-S-7 <br /> 197--22 <br />