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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL- HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA tt <br /> =Telephone Q09} 466-6781' W , <br /> ;HERMIT EXPIRES­l YYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> V' <br /> i Application is hereby made to the San Joaquifq_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 Cdunty 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 /> � � FY <br /> " Job Address � �T,-_r����/�__� City f�U Lot Size PM " <br /> Owner's Name L 'V C Address p /�" hone <br /> - c 1 <br /> Contractor Q Address '7%nse No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL EPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER El J f7 <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 /> O Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications t\ <br /> Il . <br /> ❑ Public ❑ Other f ❑ Delta Depth of Grout"Seal Type of Grout "V <br /> a,E <br /> El Irrigation 4pprox.,Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type ". .;np3 H.P, State Work Done <br /> Well Destruction ❑ Well Diam,aee Sealing Material atop 501 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION l7 (No septic system permitted if public sewer is <br /> 3 - available within 200 feet.) <br /> t <br /> Installation will serve: . Residence f. Commercial Other <br /> f� <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. ❑ 7Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ., by <br /> j LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well - Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Site Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> i 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 /> y 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 Californ' <br /> The applicant call forRuir� <br /> !t- <br /> Complete drawing on rev e. <br /> �( <br /> 4 Signed X Title: �' ? Date: <br /> FO DEPART ENT USE ONLY <br /> Application Acceptedby Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date/ <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 <br /> a - _ <br /> INF AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> EH 1428 <br /> + EH P3-241REV.,tia51 �.LJ �- !� <br />