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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ; <br /> Telephone (209).4666781 <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 Nn: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 � Xti <br /> City Lot Size PM <br /> Owner's Name lsc C ok Address t <br /> / hone <br /> Contractor ddress -- License No. Z- Phone ; <br /> TYPE OF WELL/PUMP- NEW ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE ! <br /> FOUNDATION AGRICULTURE WELLrOTHER_WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC ITI'ONS - <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavatiorf `"'M► Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of.Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I <br /> ❑ Irrigation pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -T4�H.P. A&�_ State Work Done <br /> Well Destruction El Well Diameter �ealing Material (top 501 v <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 /> available-within 200 feet.) <br /> Installation will serve: Residence Commercial— Other s' <br /> Number of living units: Number of bedrooms ,, <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. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Propertyline ' <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 /> 1 <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 us#call for all required in tions. Complete drawing on revers side. <br /> r (0Signed Title: � Date: — <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b Date 7–,19 Ayo Area o <br /> Pit or.Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> Cl Stk 466.6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE 'AMOUNT REMITTED CASH RECEIVED BY <br /> ` DATE PERMIT'NO. <br /> + <br /> EH'I'M REV.i/B5) J�� �� 6_4 7 �11j,Q <br />