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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON 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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address / <br /> CityQ Lot Si e r PM <br /> Owner's Name V` Address q t <br /> ��jj Phone 3 0" i <br /> Contractor C 4 k Address ,� �2 `I1" <br /> TYPE OF WELL/PUMP: e!–License No. 30A2-21 Phone 303 sj� <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS PiTS/SUMPS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac <br /> ❑ Public Y Type of Casing :permitted <br /> tions <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Grout <br /> Repair Work Done ❑ Type of Pump Surface Sea! Installed by <br /> H.P. State Wiseptic <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501) <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW iNSTALLATI EPAIR/ADDITION ❑ DESTRUCTION ❑ INm if public sewer is <br /> Installation will serve: Residence Commercial_ Other_ available within 200 feet,/ <br /> Number of living units:—]— Number of bedrooms <br /> Character of soil to a depth of 3 feet: �O <br /> SEPTIC TANKWater table depth <br /> PKG. TREATMENT_ PLT. ❑ <br /> L�}�TypelMfg _ - �� Capacity 6,1 No. Compartments `L- <br /> 1 S Method of Disposal <br /> Distance to nearest: Well-,l/l�— Foundation ' r <br /> Property Line� <br /> LEACHING LINE Ul*'No. & Length of lines �� <br /> FILTER BED <br /> ❑ <br /> / /� � Total length/size <br /> Distance to nearest: Well .r Foundation - r ' <br /> Property Line <br /> SEEPAGE PiTS LFY Depth .—Size <br /> Number <br /> SUMPS <br /> ❑ Distance to nearest: Well_/ CS ` Foundationt <br /> DISPOSAL PONDS 71Property U <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."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." <br /> The applicant must call fo all r wired inspections. Complete drawing on reverse side. <br /> r <br /> Signed X <br /> Title: 43 Gtr111 DDate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date <br /> Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823 7104 ❑ Tracy 835-6385 <br /> Applicant- Return all p to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE gMOUNT DUE AMOUNT REMITTED CK <br /> INFO l��jj� CASH RECEIVED 8Y DATE PERMIT NO, <br /> + EH 13.24 iREv.i/a 57 //9 /J �� <br /> EH 1428 F Cl-1�ci//�c��`� `/� <br />