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APPLICATION FOR PERMIT <br /> �\ SAN JOAQUIN LOCAL HEALTH DISTRICT S <br /> �� 1601 E. HAZELTON AVE., STOCKTON, CA t� <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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District." C / -7 <br /> Job Address a �/ �) - 116?iG--• '' Cityt5�—�Size 1�� j PM <br /> Owner's Namef �. � .s '?t,, L � <br /> Contractor °' Address - ";� ' License No. Phone <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 /> F] Public ❑ 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_ V <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 I DESTRUCTIONt (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 ❑ 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: "1 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 rryipst I for all req fired insp tions Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> Date: <br /> F D R USE ONLY <br /> Application Accepted b Date s— Area <br /> Pit or Grout Ins cti y Date Final Inspection by Dat <br /> 1 r x 1 <br /> Additional Comments: i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Mante 823- 04 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/S irvi es 16p1 E. Hazelton Ave., P.O. ox 2009, Stk., CA 9520 r <br /> ..,C'zlwn _ . d Lbw. <br /> CK <br /> FEE <br /> INFO AMOUNT CUE AMOUNT REMITTED CASH <br /> EH 13-24 '✓ /x <br /> RECEIVED BY DATE PERMITNO. <br /> + (REV.1/n5) 3� <br /> EH 14-24 5w o.,O <br />