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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON 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. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br />Local Health District. / � <�! <br />.1101 y <br />Owner's Name L-]LZit'i <br />C_ Address �_Q 11�' Phone <br />AMOUNT REMITTED <br />CK # <br />RECEIVED 8Y <br />Phone& <br />Contractor's Name <br />License No. <br />TYPE OF WELL/PUMP: <br />NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br />CASH <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ v OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br />FOUNDATION AGRICULTURE WELL- OTHER WELL PITS/SUMPS 4 <br />INTENDED USE <br />TYPE OF WELL/ PROBLEM AREA 'CONSTRUCTION SPECIFICATIONS <br />❑ Industrial <br />❑ Open Bottom' ❑ Manteca Ria. of Well Excavation Dia. of Well Casing <br />❑ Domestic/ Private <br />❑ Gravel Pack ❑ TracyType of -Casing Specifications <br />❑ Public <br />❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br />❑ Irrigation <br />--/Approx. Depth ❑ Eastern Surface Seal Installed by <br />Repair Work Done ❑ <br />Type of Pump H. P. State Work Done <br />Well Destruction ❑ <br />Well Diameter Sealing Material Itop 501 <br />Depth _ Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION' ❑ (No septic system permitted if public sewer is <br />within 200 feet.► <br />Installation will serve: <br />'available <br />Residence _i!�f Commercial _ Other <br />Number of living units:_ <br />Number of bedrooms <br />Character of soil to a depth of 3 feet: Z9,he Q ' Water table depth <br />SEPTIC TANK <br />❑ Type/Mfg Capacity. No. Compartments <br />PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br />Distance to nearest: Well Foundation Property Line <br />9 <br />LEACHING LINE <br />moo. & Length of lines/' Total length/size <br />FILTER BED <br />❑ Distance to nearest: Well Foundation Property Line <br />SEEPAGE PITS <br />r <br />❑ Depth Size ^�,� 1� N <br />/ umber <br />SUMPS <br />Distance to nearest: Well.<_v.."_ Foundation Property Line^ rS <br />� <br />DISPOSAL PONDS <br />❑ <br />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 Calif .. <br />The applicant us all r all requir inspections. Complete drawing on reverse side. <br />�J <br />Signed Title: Date: <br />OR DEPARTMENT USE ONLY ` • . <br />Appli4 <br />caion /yCjkepted by - ':Date - e <br />�. e t�l/nspectian by ` Date Final Inspection by Date <br />f 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. Hazefton Ave., P.Q. Box 2009, Stk., CA 95201 <br />+ EH 13.241REV. 1018 <br />EH 1126 <br />FEE <br />AMOUNT DUE <br />AMOUNT REMITTED <br />CK # <br />RECEIVED 8Y <br />DATE <br />PERMIT N0. <br />INFO <br />CASH <br />I <br />i`'l3f'it y <br />Lj ti2g1 <br />Tit <br />