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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (249) 466-6781 <br /> ' PERMIT EXPIRES 1 YEAR .FROM DATE ISSUED <br />+' it (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 lHealth District. <br /> Job Address ?X 1 City Lot Lot Size <br /> PM <br /> 09 <br /> Owner's Name Address z�}` / / r LV I 4 Phone " g.) <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ED WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> EEE PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <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 /> r ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ IrrigI tion �4pprox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair(Work Done © Type of Pump H.P. State Work Done <br /> FWell Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 54') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is i <br /> ,Y � <br /> / <br /> Installation will serve; Residence__L Commercial— Other available within 200 feat.) <br /> Number of living units:-/-- Number of bedrooms <br /> Character of soil to a depth of 3 feet: r Water table depth <br /> SEPTIC TANK �, Type/Mfg Capacity No. Compartments 2— <br /> F"; I - 0 <br /> PKG. TREATMENT PLT. ❑ /{ 0 Method of Disp9sal <br /> k Distance to nearest: Well �Q Foundation-` 41 <br /> Property Line :7-4 <br /> _ I <br /> 1 LEACHIING LINE igr­No. & Length of lines + tal length/size d <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> F. ->SEEPAGE PITS Depth Size .33 Number <br /> SUMPS C1 Distance to nearest: Well 1.51 Foundation <br /> I <br /> Property Line I <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: '9 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 kthe fallowing: "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 m 11 for all ired inspectio s. to drawing on rev se side. ,- <br /> Signed Title: <br /> Date. i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 9 <br /> Date ea f�A1( OU <br /> k <br /> 7 <br /> Pito Grlout Inspection by ate �I Final Inspection by to I <br /> r <br /> Additional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> A plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> i <br /> 1 <br /> _P eH 13-24(REV.15183) Z `r `" <br />