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t <br /> APPLICATION FOR PERMIT <br /> } <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES 7 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 Lot Size PM <br /> Owner's Name 10 <br /> ! Q <br /> A �_�Q Address Phone f sT <br /> Contractor Addres t^I� 'cense N ]M�� Pham SCJ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTI <br /> OWQW <br /> PUMP INSTAIILATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST. SEPTIC TANK SEWER LINESIn <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA , CONSTRUCTION SPECIFICATIONS f <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private Cl Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump I H.P. State Work Done s <br /> Well Destruction 4 ❑ Well Diameter I Sealing Material Itop 501 t <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Na 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 TAKTypelMfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. EllMethod of Disposal <br /> Distance toc nearest: Well Foundation Property Line <br /> v <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to,nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth r Size ` <br /> Number <br /> SUMPS ❑ Distance to dearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinancesr 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: "I certify that in the performance of the work for which this permit is issued,I shall <br /> laws of California." k all employ persons subject to workman's compensa- <br /> tion <br /> i <br /> The applicant st call for all requi din potions. Complete drawing on reverse side. <br /> Signed } Title: <br /> Date: + <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> rr Date Area <br /> Pit or Grout Inspection b f i Data Final Inspection by <br /> a Data <br /> Additional Comments: <br /> ❑ Stk 486-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-8385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO ASH RECEIVED 8Y DATE PERMIT'No. <br /> + EH 13-241REV,1/a 5) <br /> EH 1425 Irin <br /> ,� /� <br />