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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 /> v - (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 /> f Job Address 6ff C� <br /> City Lot Size <br /> Owner's Name ' Address ' <br /> Phone`, <br /> Contractor dress �~ License No. Phone fJ <br /> TYPE OF WELL/P MP: NEW MLL ❑ F WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ t r r SYSTEM REP,_'AIR O OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES a Y DISPOSAL FLD. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL . OTHER WELL _ PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br />` ❑ Industrial ❑.Open Bottom .r,, ❑..Manteca_ Dia. of Well ExcavationDia:"of Well Casing' <br /> ❑ Domestic/Private ❑ Gravel Pack I ❑,,Tracy Type of Casing Specifications <br /> ❑ Public ❑ Otherl <br /> F ❑ Deta Depth of Grout Seal �. M _ T <br /> ' ype of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern) `Surface Seal Installedlby <br /> Repair Work Done ❑ Type of Pump s H.P. —-_.State.State Work Done <br /> Well Destruction ❑ Well Diameter ' � *' Sealing'Material (top 50'1 <br /> Depth—_t t Filler Material (Below 501 s 2,^" ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATIONREPAIR/ADDITION Oyj DESTRUCTION ❑ {N0-septic system permitted if public sewer is <br /> -,-available within 200 feet.1 <br /> Installation will serve: Residence Commercial— Other r <br /> Number of living units: Number of bedrooms i <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. ❑ f r Method of D's I <br /> Distance to nearest: Well 1 DD Foundation _ Property Line ._. <br /> LEACHING LINE 1-11No. & Length of lines ® T%al length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation .. Property Line._. <br /> SEEPAGE PITS ❑ Depth ize. -_ r <br /> Number <br /> UM 11Distance to nearest: .Well� Foundation . Property Line r <br /> DISPOSAL PONDS ❑ e <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 t <br /> employ arty person in such manner A to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature 1___11 <br /> tion <br /> 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:" S <br /> The applicant must call.'foreall r wired inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> .M.— FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> .Pit or Grout Inspection by Date inal Inspection by Date S <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 EJ Manteca -823-7104 ❑ Tracy 8354M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECENED BY DATE PERMIT N0. <br /> INFO CASH <br /> i <br /> t <br /> + EH -24(REV <br /> EH418 - p �b�VF/s5177� <br />