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6S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E- HAZELTON AVE., STOCKTON, CAa <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 62 3 13 S iN City Size PM <br /> Owner's Name .480,0' z— Phone 4, —4W <br /> Contractor Address License No. Phone <br /> TYPE OF WELLIPUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ r <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL PROP. LINE <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON TION SPECIFICATIONS <br /> El Industrial ❑ Open Bottom ❑ Manteca ia. of Well Excavation Dia. of Well Casing "C 113 <br /> ❑ Domestic/Private ❑ Gravel Pack LlTrac Type of Casing Specifications �f1W <br /> ❑ Public ❑ Otherelta Depth of Grout Seal Type of Grout <br /> El Irrigation --Approx. th ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type ump H.P. State Work Done <br /> Well destruction Liell Diameter Sealing Material (top 50') <br /> Depth Filler Material [Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo 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 <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 1 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 m call for all requir inspections. Complete drawing on reverse side. <br /> Signed Title: _ Date: 'tq—gl <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �"� Area 0 <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> Additional Comments: <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, Stk., CA 95201 <br /> FEE INFO AMOUNT�DyUE AMOUNT REMITTED C S RECEIVED BY DATE PERMIT NO. <br /> 10, <br /> + EH 13241REY.iia5i ""���f/ - ...� ,.d / �J <br /> Q/f <br /> EH 5428 <br />