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1 F✓ * `.• r <br /> ; �• APPLICATION FOR PERMIT <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) I <br /> Application is he+eby 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 es cfY—�4 <br /> City Lot Size PM <br /> 9 r <br /> Owner's Name Address Phon5� w /a <br /> t a 7 �' p <br /> Contracto H <br /> Address P9Z/d� ense � /t� Ph e J Q <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 FLD. INE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL _PROBLEM.AREA,-„CONSTRUCTION ICATIONS. <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype of Casing Specifications <br /> .1=1 Public M F1 Other a Depth of Grout Seal Type of Grout _ <br /> I I Irrigation _..Approx t I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ o Pump H.P. State Work Done <br /> i Well Destructio Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE bF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION 1 1 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 /> cuu <br /> SEPTIC TANK Type/Mfg Capacity r 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 /> i <br /> SEEPAGE PITS Depth Size Number ! <br /> f SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 D(§trict. <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.” Contractoes 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 applica st call for all qu' d inspections."Complete drawing on re se-side. <br /> i Si ed X Title: –� W–� - – Date: . <br /> 0 <br /> FOR DEPARTMENT USE ONLY <br />' Application Accepted by Date – Area <br /> Pit or Grout Inspection b Date Final Inspection by Date <br /> I <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 /> s <br /> FEE AMOUNT DUE AMOUNT REMIT-TEL) CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> t-EH13-Y41REV.i/a5) <br /> EH 14-2a 111 <br />