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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT r/ <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) <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/of 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 /> Lot Size PM <br /> Joh Address cc <br /> �a city_ �c 1U S i <br /> �� —� U S . . ,� Phon <br /> Owner's Name �� Address z <br /> Contractors Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL C5WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ I <br /> SEWER LINES DISPOSAL FL[). OP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK LL PITS/SUMPS <br /> FOUNDATION AGRICULTURE WELL O <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON ION SPECIFICATIONS pia. of Wel! Casing <br /> El industrial El Open Bottom 17 Manteca Dia. of Wel! Excavation Specifications <br /> ❑ Domestic I Private ❑ Gravel Pack racy Type of Casing <br /> ❑ Delta Depth of Grout Seal Type of Grout <br /> ['i Public 171 Other _ <br /> 1 1 Irrigation ­Approx. Depth 4 I Eastern Surface Seal Installed by n <br /> Repair Work ❑ Type of Pump <br /> H P State Work Done ) <br /> W struction ❑ Well Diameter Sealing Material (top 50'1 <br />` Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION (:I -DESTRUCTION! I (NailabPar <br /> Pelwithin 200 feetc system .) if public sewer is <br /> Installation will serve:' Residence Commercial_ Other <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil.to a depth of 3 feet: <br /> I Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> Total length/size <br /> LEACHING LINE 0 No.;& Length Yof lines ' <br /> Property Line <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> f <br /> { SEEPAGE PITS I i Depth Size Number.- <br /> E SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> l d that the work will be done in accordance with San Joaquin county ordinances, state laws, <br /> I hereby certify that I have prepared tand <br /> his application an <br /> rules and regulations of the San Joaquin Local Health District. <br /> following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the <br /> such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> employ any person in ss of the worts for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> certifies the fallowing: certify that the performance <br /> tion laws of California." — <br /> The ap cant st cal for quired inspectio s. Complete drawing on reverse side. <br /> Signed <br /> Title: 6 W ju cw., Date: <br /> FOR DEPARTMENT USE ONLY <br /> Date r Area <br /> k Application Accepted by kv— � <br /> FDate Final Inspection by Date <br /> Pit or Grout Inspection by <br /> I � <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 3-7104 ❑ Tracy 835-6385 <br /> " Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. ox 2009, Stk., CA 95201 <br /> r <br /> FEE AMOUNT DUE AMOUNT REMITTED AS RECEIVED BY DATE PERMIT NO. <br /> ' INFO <br /> r EH 13-24(REV. <br /> EH 14-28 <br />