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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T 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. p/ <br /> Job Address A 30 5 ��P,L4 T)EP City a Size PM <br /> Owner's Name �' rtit �. Address Phone <br /> Contractor 'kof\L-_f T7__,AU Address L fl, t4ense No. O Phone ��S <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 FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> F-1 Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public Cl Other [-] Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ____Approx. Depth I 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done y <br /> Well Destruction ❑ Well Diameter Sealing Material /top 501 N <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I AIR/ADDITION l I DESTRUCTION { I (No septic system permitted if public sewer is <br /> � ��'' available within 200 feet.) <br /> Installation will serve: Residence L—Commercial Other <br /> Number of living units: __/_ Number of bedrooms. <br /> Character of soil to a depth of 3 feet: NJSJ_Z> Water table depth <br /> SEPTIC TANK L5-�ypoMfg C Dol r r_r—j f z;2- Capacity / c-® D No. Compartments f <br /> PKG. TREATMENT PLT_( _ p Method of Disposal �e <br /> Distance to nearest: Well Foundation/S Property Line <br /> LEACHING LINE & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ( I Depth Size Number <br /> SUMPS 0 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, an <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 /> certifi he following: "1 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 I ws o ifornia." <br /> The applicant us ll fo all uired i spe i ns. Co I wing on rove 0 side. _ <br /> p <br /> Signe tle: . G4/S� Date: <br /> FOR DEPARTMENT USE ONLY 2 <br /> Application Accepted by `` Data tVArea 13 <br /> Pit or Grout Inspection by Date Final Inspection by Date4-61—,R7 <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 /> �?`9 3�4( <br /> FEEINFO AMOUNT DUE AMOUNT REMITTED CASH CK 0 RECEIVED BY ` DATE PER <br /> INFO <br /> ♦ EM14-26 <br /> 3-24(REV.i/e51 4�l . <br />