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s 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. <br /> Job Address City /iLLot Size PM <br /> Owner's Name - W i e ,! ddress / �� � Iy�c Phone f % > <br /> �. �. <br /> Contractor - Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAI OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLO- PROP. LINE <br /> FOUNDATION AG LTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA NST CTION SPECIFICATIONS <br /> ❑ industrial ❑ Open Bottom ❑ Manteca Dia. ell Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Ty of Ca Specifications <br /> f� Public Cl Other 171 Delta pth of Grout Type of Grout _ <br /> I I Irrigation __Approx. Depth i 1 Eastern Surface Seal Installed b <br /> Repair Work Done ❑ Type of Pump H.P State k Done <br /> Well Destruction D Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> vailable 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 Q No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl 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: 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 laws of California." <br /> The applicant must call for all require s g o arse side. <br /> Signed X �- t�40itle: - C ' <br /> Date: <br /> DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by �l Date Final Inspection by ""�"`��`�'`� Date <br /> Additional Comments: � �v_ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 8,23-7104 ❑ 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 OUNT DUE AMOUNT REMITTED CK,# <br /> INFO RECEIVED BY �DATpE�f1 PERMIT <br /> %-NO. <br /> 1,0 a EH 14-28(REV.t/8 5) Sr� ; !tea � /9 1�/(e7 <br />