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i <br /> 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 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 /> Q !� <br /> Job Address / O �]� f A_ �' City 'Lot Size PM <br /> Owner's Name Address t°V Phone <br /> Contracto dress Q { Z License No]613 �� Phone 66� <br /> TYPE OF WELL/PUMP: NE. WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Indd ' ❑ Open Bottom Ll Manteca Dia. of Well Excavation Dia. of Well Casing <br /> f�4 estic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ stern Surface Seal installed by <br /> Repair Work Done Eh�Type of Pump State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No 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 TANK ❑ Type/Mfg _ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of,Disposal 4 <br /> 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 ❑ Depth Size Number <br /> SUMPS ❑ 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 Ii nt'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 p on in such nner as to become subject to workma 's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the (lowing: "I ce that in the pe rmanceZetewor <br /> r or which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws California." <br /> The app cant r all re r omowing onre r i <br /> Signed Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Acceptedby24� Date__��'�. _ Area dZ <br /> Pit or Grout Inspectio y Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 IRM 1/ss) 71 t-7� <br /> EH 14-28 �+�� Zoz <br />