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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEARyFROM 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 /> f 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 rG G Cit <br /> _ - Y Y Lot Size PM <br /> ---Owners Name• - - � <br /> Address- <br /> - . .Phone <br /> Contractor Address <br /> License No. Phone I <br /> —TYPE OF.WELL./PUMP:. —NEW License <br /> WELL fiEPLACEMENT.❑ ,DESTRUCTION ❑ <br /> PUMP INSTALLATION 71 SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. OTHER ❑ <br /> PROP. LINE � <br /> FOUNDATION AGRICULTURE WELL OTHER WELL _ <br /> PITS/SUMPS ' <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open <br /> Bottom Manteca Dra- of Well Excavation <br /> EJ Domestic/Private ❑ Gravel Pack - ❑ Trac Dia. of Well Casing <br /> Y Type of Casing <br /> ❑ Public F1 Otherf 1 Delta Depth of Grout Seal Specifications LL <br /> I I Irrigation - pprox.1Depth I I Eastern` T. Type of Grout <br /> A <br /> Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump . .H.P. <br /> State Work Done _ <br /> Well Destruction E2 Well Diameter{ Sealing Material (top 50') J <br /> f (t <br /> Depth 'Filler Material {gelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATlON.L.1_ REPAIR/ADDITION DESTRUCTION I 1 INo septic system permitted i—public sewer is W <br /> Installation will serve: Residence'- ' Commer ial�� Other available within 200 feet.] <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet: a. <br /> SEPTIC TANK Water table depth <br /> TypelMfg _ _` ..Capacity .'�`- y-_�. <br /> PKG. TREATMENT PLT.❑ F s NoCiimpartments <br /> "+ .. Method of Disposal <br /> Distance to nearest: Well Foundation_ �_ Property Line (Z f> Q <br /> LEACHING LINE ❑ No. & Length of lines ` <br /> Total length/size' <br /> FILTER BED ❑ Distance to`nearest:� Well Foundation Property Line <br /> - - r <br /> SEEPAGE PITS I I _Depth Site ; <br /> , . Number <br /> SUMPS \� <br /> �1 Distance to W61i Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <br /> I hereby certify that I have prepared this application and that the v3ork 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: "!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." ' a, , <br /> 6 ! <br /> The applicant must call for afl required inspections. Complete drawing on reverse side. <br /> Signed X <br /> Tille: _ �,� <br /> J Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> Pit or Grout Inspection by Date Final Inspection by �7 <br /> Date Z_ <br /> f 7 <br /> Additional Comments: <br /> L7 Stk 466-6781 0 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 /> FEEi <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y <br /> CASH DATE PERMIT'NO. <br /> . EH 13-24(REV, <br />