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APPLICATION FOR PERMIT <br /> 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 " "" City Lot Size PM <br /> � r- <br /> Owner's Name Address <��" Phone <br /> "Ci5r_iffctof Address "License No. 'Ptfone-""'"" , `^ z <br /> TYPE OF WELL/ NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ j. <br /> € PUMP INSTALLATION ❑'" SYSTEM REPAIR El OTHER ❑ <br /> i i <br /> r DISTANCE TO NEAREST: SEPTIC TANK .SEWER LINES DISPOSAL FLD. PROP. LIN <br /> r FOUNDATION I AGRICULTURE WELL OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA _ CONSTRUCTION SPECIFICATIONS <br /> YIndustrial ID_Open Bottom ❑..Manteca*i' Dia. of Well Excavation Dia. of Well Casing <br /> ❑}Domestic/Private Ti Gravel Pack a❑Tracyl�. Type of Casing Specifications <br /> l'7 Public t CI Other y 3CljDelta.k w Oepfh of Grout Seal Type of Grout <br /> I i Irrigation _.-Approx. Depth I I.Eastern -Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Z ►..r-_­1• h9 <br /> Well Destruction ❑ Weil Diameter Sealing Mate ria l'ltop,50'i <br /> F <br /> j Depth r Filler Material (Below <br /> TYPE OF SEPTIC WORK;' NEW INSTALLATION I 1 REPAIR/ADDITIONPC DESTRUCTION t 1 [No septic system permitted if public sewer is <br /> i available within 204 feet.I <br /> Installation will serve: Residence`� CommercialJ111er "* %a / <br /> Number of living units: Number-of bedrooms <br /> Character of soil to a depth of 3 feet: �� s } Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments / <br /> PKG. TREATMENT PLT. ❑ t Method of Disposal r <br /> ''� Distance to nearest: Well Foundation Property Line ,; ` <br /> HING LINE ❑ No. & Length,of lines Total lengtWsize <br /> FILT ❑ Distance to neatest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size- Number <br /> f <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ F <br /> I hereby certify that t have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and I <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 app t_must c �Ifor all reqfuire�ms ions. Co����la_te dyrawing on rev side. <br /> Sign d �« V un A11-11 �C/ _ Title: Date: 3/2 f <br /> R E ARTMENT USE ONLY <br /> 1 <br /> Application Accepted by Date Area <br /> i Pit or Grout Inspection by Dat Final"Inspection by � � Date � O <br /> ` Additional Comments: ^- S a <br /> ❑ Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Sik., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED SH RECEIVED BY DATE PERMIT'NO. <br /> +.EH1 -24(REV.i/n5Y <br /> EH 144-28 <br /> i <br /> r3 <br />