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• 11 � L! <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address l c� Cit Lot Size L ISO PM <br /> 7�e <br /> Owner's Name & S��� ,r,Address �i�.� y � <br /> s <br /> s� Phone <br /> Contractor AddressLicense No. aZ__ffZ—Phonate <br /> TYPE OF WELL/PUMP: NEW WELL ❑ W C L REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE !/1 <br /> FOUNDATION AGRICULTURE WELL R WELL PITS/SUMPS V <br /> INTENDED USE TYPE OF WELL PROBLEM AREA TRUCTION SPECIFICATIONS N <br /> ❑ Industrial ❑ Open Bottom ❑ Ma Dia. of Well Excavation Dia. of Well Casing co <br /> ❑ Domestic/Private ❑ Gravel Pack Tracy Type of Casing Specifications <br /> 1-1 Public I 1 Othe 11 Delta Depth of Grout Seal Type of Grout , ..� <br /> I I Irrigation --Approx. Depth l I Eastern Surface Seal Installed by _ <br /> Repair Work D LJ Type of Pump H.P. State Work Done_ <br /> Well ruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material /Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION ( 1 DESTRUCTION (No septic system permitted if public sewer is <br /> 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 n <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments V <br /> PKG. TREATMENT PLT- ❑ Method of Disposal J <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 ) Depth Size Number <br /> SUMPS Ll 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,1 shall employ parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applican must call for all re wired inspections. Complete drawing on reverse s' <br /> Signed X Title: Date: <br /> FOR DEPAR4ENT USE ONLY � <br /> Application Accepted by Date r Area <br /> Pit or Grout Inspectio Date Final Inspection by Date <br /> Additional Comments: " ` <br /> ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 623-7104 racy 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT'NO. <br /> r EH 1 -24 1REV. /N 51 � <br /> EH 144-28 <br />