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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR 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/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 11/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. / <br /> Job Address CL01 ity Em7mmLot Size PM <br /> Owner's Na IV4Addressc� 3 6A-0—: phone <br /> - ��- <br /> Contractor Addre License U <br /> Ph e <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. PROP. LINE <br /> FOUNDATI AGRICULTURE WELL OTHER WELL P <br /> INTENDED USE TYPE OF WELL PROS A CONSTRUCTION NS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Excavation Dia. of Well Casing \ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tra Type of Casing Specifications <br /> (i Public F1 Other Delta Depth of Grout Seal Type of Grout ` <br /> I I Irrigation _Appr , epth [ I Eastern Surface Seal Installed by <br /> Repair Work Done El T of Pump H.P. State Work Done _ <br /> Well Destruction Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 501 <br /> TWE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION l I DESTRUCTI (No septic system permitted if public sewer is G\ <br /> available within 200 feet.) u <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 Capacity 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 /> SEEPAGE PITS I l Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Properly 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 Diltrict. <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 applica ust call for all required ' c ' ns. omplete drawing on rev side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted bDate '�r Area <br /> Pit or Grout Inspe y Date Final Inspection by Dat <br /> Additional Comments: �'��� _,__ <br /> ❑ Stk 456-6781 ❑ Lo 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH <br /> 13-24(REV.riH5) :Ak / ` iyy� <br /> EH 14"29 ,/`�Sz <br />