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APPLICATION FOR PERMIT SCANNED <br /> 1n SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> ° 4 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 applicatnn 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. l <br /> Job Address'l <br /> _— City Lot Size PM <br /> Owner's Nameffe& _ ( /(' /Address <br /> Phone <br /> Contractor ess License No. ' / Phone v / <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br /> 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 t\�. <br /> j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <br /> ❑ Industrial C7 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P, State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 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 t� <br /> 1J <br /> Installation will serve: Residence Y Commercial— Other available within 200 feet.) <br /> Number of living units:I Number of bedrooms 1 <br /> Character of soil to a depth of 3 feat: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 1`7 / Method of Di osal <br /> Distance to nearest: Well Foundation-A0 Property Line s _ <br /> LEACHING LINE Ll No. & Length of lines TptaI length/size / <br /> FILTER BED ❑ Distance to nearest: Well 112i_ Foundation Property Line _ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Ik 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 m t c r all requpections. Comp a awing on r rse side. <br /> Signed Title: 1 <br /> -�� Date: <br /> FOR DEPARTMENT USE ONLY <br /> 1 r. <br /> Application Accepted by -'' =C• t'i" _ / <br /> - Date <br /> � "` ! <br /> Area <br /> orGrout Inspection by Date Final Inspection by"- J <br /> Additional Comments: <br /> ❑ Stk 466-5781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-5385 <br /> Applicant- 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# RECEIVED BY <br /> INFO CASH DATE PERMIT"NO. <br /> + EH 13-24{REV.1/e 5) rr f��? <br /> j_, / �J <br />