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`. ..i <br /> 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 /> Job Address's T � I `` , t���.�D���J 1``r C'R�l _ Lot Size PM <br /> Owner's Name-S o�AE. \��I,tF �Y 0�-dMdrEsl;""1 `` /� Phone <br /> Contractor's Name I-FE,Vr INL_1b1NL $icense No. I `'T l Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ 1 <br /> r PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ �l <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 /> ❑ Domestic/Private ❑ 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 l <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <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 V'Other �/j <br /> Number of living units:_ Number of bedrooms -. _ Lam--.. <br /> Character of soil to a depth of 3 feet: ater table depth <br /> r <br /> SEPTIC TANK <br /> El <br /> ity o. Compartments <br /> PKG. TREATMENT PLT. El Method of Disposal <br /> Distance to nearest: Well - Fcundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r. SEEPAGE PITS ❑ Depth Size Number <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: "IN ify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- <br /> tion la t California." <br /> The applicant call for all qu' d in ction . o lets drawing on�r 3verse side,.p� <br /> Signed (� <br /> itle:Tl�-.J�.4 .CfL� Date: v f / <br /> EP ENT USE ONLY <br /> Application Accepted by Date Area 7 / <br /> Pit or Grout Inspecti n — - Final Inspection by Date <br /> Additional Com ts: en <br /> ❑ Stk 466- ❑ Lodi 389-3621 MlKteca 823-7104 ❑ Trac 83 ` <br /> r Applicant - Ret6rh a I c pies to: Environmental Health Permit/S ices 1 I.E. azelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> / <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> EH 1324(REV. 10/431 S Cl <br /> GH 16M <br />