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s APPLICATION:FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT n. ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 4 . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDA <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 fi <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 S F S i/Y . City Lot Size PM <br /> oW/+4 n '?F-17; <br /> r� <br /> --TOwner's-Name- Address Phone <br /> Contractor Address License No. y_ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ y r. <br /> PUMP NSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ No; <br /> DISTANCE TO NEAREST: SEPTIC T SEWER LINES _' DISPOSAL FLD. PROP.,LINE - =- <br /> FOUNDATION ULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM CIFIC ATIONSd <br /> ❑ Industrial ❑ Open Botto Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ ack ❑ Tracy Type of Casing t Specifications <br /> LlPublic ❑ Other ❑ Delta Depth of Grout Seal of Grout <br /> Cl Irrigation ---Approx. Depth ❑ Eastern Surface Seal-,installed by - <br /> Repair Work Done ❑ Type of Pump H.P. _State Work Done <br /> '1 F <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50es` r, <br /> - Depth Filler Material {Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO14 INo septic-system permitted if public sewer is r <br /> r,F 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 r t {` "� Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 11. . Method of Disposal r a• <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 ❑F Distance to nearest: Well Foundation Property Line r <br /> DISPOSAL PONDS ❑ M <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 applicai ust call for all req a inspect; s. Complete drawing on"reverse side. Y /J <br /> Signed X Title: �/� f'h/ > Date: <br /> FOR DEPARTMENT USE ONLY �I <br /> Application Accepted by Date — ` Area <br /> Pit or Grout Inspection b Date Final Inspection by Dat `AA <br /> 5 <br /> Additional Commentst '��� ., PIP <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca M-7104 ❑ Tracy 835-6385 Im <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 C RECEIVED BY DATE PERMIT NO. <br />