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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.548 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> y <br /> Job Address Cit <br /> Y Lot Size PM <br /> Owner's Nam <br /> /-k—&At�—� <br /> fte,&, <br /> / . Phone <br /> Contractor L�7 �.�JkLP / Address �A icense No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER L.] <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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> %t Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public F1 Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done it Type of Pump H.P. 6 State Pork Pone <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'I <br /> Depth Filler Material (Below 50') r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION I I INo septic system permitted if public sewer is vl <br /> available within 200 feet.} <br /> Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms v, <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 ❑ Na. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> n <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L7 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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: "1 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 applicant m 1st a} fat all required inspections. Complete drawing on re se si <br /> Signed X T <br /> Title: Date: L.. l <br /> FOR EPARTMENT USE ONLY –7 <br /> Application Accepted by Date / �V F/� <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection b D <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 0 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 <br /> INFO *MOUNT <br /> CASH DATE PERMIT�NO. <br /> DUE AMOUNT REMITTED CK RECEIVED BYEH 4 IREV.1 i n 51 <br /> EH 14-2Lqs1`9 X377 ��/� ��7 �D- 334 <br />