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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA I`ll <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES'1 YEAR FROM DATE ISSUED N� <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. p <br /> Job Address ,i(1-ds�fYl G!'iG[�(/��a r j <br /> Ci Lot Size PM. <br /> 111 <br /> r <br /> Owner's Name ddress Phone <br /> Contractor Address —License No. Phone <br /> TYPE OF WELL/PMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <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 /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane� 'I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth p Filler Material (Below 501 I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is 1 <br /> available within 200 feet.) f <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: r. Water table depth I <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 tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> w <br /> SEEPAGE PITS ❑ Depth. 4 Size <br /> Number <br /> SUMPS ❑ Distance to nearest Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �-- <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 <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 must call for all required inspections. Complete drawing on reverse side. <br /> b <br /> Signa X Title:' F <br /> Date: — 3 .-9- <br /> FOR DEPARTMENT USE ONLY 7,,.�� <br /> Application Accepted by Date 30 Area <br /> Pit or Grout Inspection _5U� <br /> Doil <br /> ate 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO n r� �jH <br /> + EH 13-24 IREv,t i x sY IpX� <br /> EH 1426 (�C_J(/ Q <br />