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f <br /> .7 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209) 466-6781 ��t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUEDpW <br /> (Complete in Triplicate) [ A'�!> <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. �J <br /> Job Address '/ City Lot Size PM <br /> Owner's Name &A� t-a- ' <br /> Phone /d <br /> 0 A+ "%k L <br /> Contractor 44 — Address s License No. Phone p�� <br /> TYPE OF WELLIPUMPr NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ Wf _ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ vl1 <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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public i ❑ Other } ❑ Delta Depth of Grout Seal Type.of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern SurfaceSealInstalled by <br /> Repair Work Done ❑ Type of-Pump M.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth- a Filler Material iBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION O DESTRUCTION/ek-(No septic system permitted if public sewer is <br /> ! j y available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: iNumber of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth <br /> SEPTIC TANK ❑ Type/Mfg x Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ r, ,. 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 ❑ Depth Size Number <br /> SUMPS ❑ 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title:' Dater /r 747 <br /> j <br /> ARTMlENT USE ONLY ` <br /> Application Accepted by Q�U�.w �__ Date 5 Area ©``� �,'� <br /> Pit or Grout Inspection by Date Final Inspection tty/ DatsdLL__._4 j <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354685 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/B 5) /� <br /> EH 1428 / !(�V <br />