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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) r <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 Sf'a To/y f City -OS CA Lot Size PM <br /> Owner's Name 4//,*lF A- SA C/$/'J Address Phone 3;opy <br /> Contractor Address/ License No. <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---ss - g <br /> INTENDED USE 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 /> El 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 a <br /> t Depth Filler Material {Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION El REPAIR/ADDITIONJO DESTRUCTION El (No septic system permitted if public sewer is <br /> - - . -1— r available within 200 feet.) <br /> Installation will serve: Residence<< Commercial_ Other rr- <br /> Number of living units: Number of bedrooms I <br /> Character of soil to a depth of3.fae1: Ao lM ! Water table depth <br /> SEPTIC TANK ❑ Type/Mfg, Capacity >r '` ' No. Compartments <br /> PKG. TREATMENT PLT. ❑ 3 Method of Disposal <br /> Distance to,nearest: Well Foundation Property Line I <br /> i <br /> LEACHING LINE W` NO. & Length of lines "' !" i Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundat1orf•"'s�" _ Property Line- y� s <br /> S - 'SEEPAGE PITS ❑ Depth 4 Size Number t � <br /> SUMPS ❑ Distance to nearest: J`' Well Foundation Property Line <br /> DISPOSAL PONDS �'❑'"mak r ` t <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 iri 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 woPkman'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." �r. <.oe ; <br /> The applicant must c I for all required inspections. Complete drawing on reverse side. <br /> A;r 111 <br /> Signed Title: Date: x <br /> FOR DEPARTMENT USE ONLY - <br /> Application Accepted by • �' ;Date y / Area 06 <br /> Pit or Grout Inspection by f " Date ` Final Inspection;byDate 2 �� <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E: Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK `.. RECEIVED BY DATE PERMIT N0. <br /> � EH13-241REV.1/a 5) <br /> EH 14-26 <br />