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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <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 /> Coca[ Health District. <br /> Job Address i" City ejfA L s Lot Size PM <br /> — <br /> V <br /> 6 gCAddress �' t' ��u •� �*' Phone <br /> Owner's Name �f <br /> Contractor's Name <br /> "License No. _ - - ph�ne�r <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 /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom El 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 _�4pprox. Depth ❑ Eastern Surface Seal Installed by .' <br /> IState Work Done <br /> l Repair Work Done ❑ Type of Pump H.P. <br />(� Well Destruction ❑ Well Diameter Sealing Material atop 50') <br /> DepthFiller Material iBelow 501 f <br /> . TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION 'DESTRUCTION ❑ iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence-Aef' Commercials - Other--:-- <br /> Number <br /> ther C <br /> Number of living units:_/-- Number of bedrooms' 7L <br /> Character of soil to a depth of 3 feet: 'Water table depth T <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> a <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;a2 I—r-Foundation r-7-- Property-Line <br /> SEEPAGE PITS ❑ Depth Size �` '' Number <br /> SUMPS ❑ Distance to nearest: ,, Well Foundation Property Line " <br /> DISPOSAL PONDS ❑ � `�- ^�' <br /> hereby certify that I. hav-e.prepared thisfapplication 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 cW[icensed•agent's_signature certifies the following: "I certify.that in the pert mance of the work for which this permit is issued, I shall not <br /> employ any person in su0rmanner 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 r uired.inspections. Complete drawing on reverse side. c <br /> �.+,' Date: ';2Signed Title: ¢; <br /> FOR OEPARTMENT USE ONLY °r� — a , <br /> .' Date Area <br /> Data Final Inspection by date <br /> +} Application Accepted by , _ <br /> iy <br /> Pit or Grout Inspection b Z— �� <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ 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 j <br /> MOUNT REMITEFEE AMOUNT DUE -CASH "RECEIVEDBY --"- �"DATE ...ee.. PERMIT"NUr� ^`r <br /> INFO <br /> + EH 13-24(REV.10183) <br /> cw r`7A <br />