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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. FiAZELTOiV AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I 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 /> madein 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 .JJ. • 4&az City Lot Size PM <br /> Owner's Name /6 SeKdrw ZZ,2 N , ��t_ .Y r Phone <br /> Contractor Address �� nse No. 3 Phone <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 UA ,TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �! <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ 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 H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200-feetl <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 t ble depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No�'Cofnpartments <br /> PKG. TREATMENT PLT. ❑ Method of-Disposal <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 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 employ persons subject to workman's compensa- <br /> tion laws of California-" <br /> The applicant mu t call for all required inspections. Complete drawing on revere side. <br /> Signed- _ Title: [/ Q/r-1 Date: f �� <br /> -� FOR DEPARTMENT USE ONLY9-7 Area <br /> _ <br /> Application Accepted by4 Date ~ <br /> Pit or Grout Inspection b Date Final I 2 <br /> pe y tion by Date <br /> Additional Comments: �� �L` -TVr d Wt <br /> ❑ Stk 466-6781 El Lodi -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 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED OK RECEIVED BY DATE ry.J PERMITNO. <br /> + EN 13-24(REV.tits sl va <br /> EH 14-2a <br />