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A <br /> APPLICATION FOR PERMIT <br /> a SAN JOAQUIN LOCAL HEALTH.DISTRICT <br /> 1601 E. HAZE 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 i� J City SLA Lot Size v o PM <br /> Daa"d <br /> Owner's NameAddress _� .'! �f2�� Phone 2' <br /> r <br /> Contracto "ess, <br /> _�� __ �. License No. Phof � J.7 3 2 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ "WELL REPLACEMENT ❑ DESTRUCTION ❑ . <br /> r 4` PUMP INSTALLATION ❑ SYSTEM REPAIR•❑ (7THER'❑ <br /> ODI,STANC_E TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F C PROP.'!INE <br /> f FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO CTION SPECIFICATIONS I ` <br /> ❑ Industrial ❑ Open BottomF* ❑ Manteca Dia:'of Well Excavation Dia. of Well Casing <br /> ` ❑ Domestic/Private ❑ Gravel Pack p y Type of Casing Specifications <br /> 1-1Publicj ❑ Other �' ❑ Delta. Deptti'of Grout Seal Type of Grout <br /> ❑ Irrigation Depth ❑ Eastem Surface Seal Installed by + <br /> Repair Work Done. ❑ Type of Pump H.P. State Work Hone <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50 i <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ElREPAIR/ADDITION ❑ EST CTION (No septic system permitted if p lic sew r is <br /> ` available thin 200 feet <br /> Installation will serve: Residence Commercial . _Other ���// �(�-lay '"� <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/Mf Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> j Method of Disposal <br /> j 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 >r136pth Size Number ' <br /> SUMPS } ❑ Distance to nearest: Well <br /> Foundation Property,Line <br /> DISPOSAL PerNDS ❑ <br /> hereby celrtify"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 man -_r as to become subject to_wo►kmpn's compensatio6 laws of California.",Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify t t 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 m t call for all r wired ins ctions. Complete drawing on reverse side. `j <br /> Signed X ' Title: _�"y[.( R } - Date: <br /> FOR DEPARTMENT USE ONLY s +rIy�Mk¢—y <br /> Application Acceptd by Date <br /> I .,0g��J <br /> Pit or Grout Inspecti Data Final Inspection by �k+ Date6!- a <br /> { t �j <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 Tracy -835- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH t k RECEIVED BY DATE T PERMIT NO. <br /> + EH 13-24 1 REV.)/a 5) <br /> EH 1428 r , <br />