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APPLICATION FOR PERMIT �*�.�n� <br /> r SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-67815 <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' Tlh� * _ - ----- ��ac/t'-' ot Size PM <br /> (4 Owner's Nam ty``]�` `-'�-O� � )`� Phone <br /> } t1 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ O <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 /> El Domestic/Private ElGravel Pack ❑•Tracy Type of Casing Specifications <br /> El LD ❑ Delta Depkof Grout Seal Type of Grout <br /> -- <br /> ❑ Irrigation _Approx. Depth­❑ Eastern Surface Seal Installed by <br /> . <br /> Repair Work Done Ll Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 r <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONIQJNo septic system permitted if public sewer is <br /> / vailable within 200 feet.) <br /> Installation will serve: Residence— Commercial Other <br /> Number of living units: Number of bedrooms 4 <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 ❑ No. & Length of lines Total length/size <br /> FILTER BED 0 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, 1 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 call f;g���on p te-drawingreverse side. <br /> f <br /> Signed Title ' ©mayy i `,,i a Date: a . <br /> FOR DEPARTMENT USE ONLY J <br /> Application Accepted by Date�` ` O .--� Area <br /> Pit or Grout Inspection bi <br /> I J Date Final Inspection by Date-3 17 <br /> Additional Comments. r$�87 4- > <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 h M nteca 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 AMOUNT DUE AMOUNT REMITTED CASH/CK RECEIVED BY DATE PERMITT'NO. <br /> + EH 13-24(REV,1/6 5) a� � ' �`..'// /- o <br /> EH 14.28 ++GG�aJJ <br />