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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address �Olv r�`�` City Lot Size PM <br /> tj <br /> Owner's Nam�Vei�L��.(t7 1�.Ltt� Address- U ZCgY1U � G-` Phone J% - <br /> 6c I \ aQ G' �� S L O-2 Z� Phone `r✓ J slos__Contract � � 0 �O Address License No.• <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ 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 <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 /> 1'I Public ❑ Other 1-1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _ Approx. Depth 1 I 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 50') �. <br /> Depth ler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPA/ADDITION 5< DESTRUCTION I I (No septic system permitted if public sewer is <br /> o/ available within 200 feet.) <br /> Installation will serve: Resi ence Commercial Other _ <br /> Number of living units: Number of rooms /� <br /> Character of soil to a depth of 3 feet: Water table depth <br /> 1 <br /> SEPTIC TANK Type/Mfg Capacity-A)In_ No. Compartments �" ) <br /> PKG. TREATMENT PLT. ❑ _ ( Method of Disposal <br /> Distance to nearest: Well y Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size _ <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size _ Number <br /> SUMPS 11 Distance to nearest: Well Foundation Property Line 17) <br /> DISPOSAL PONDS 11 <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 "h <br /> call for r uir inspections. Complete drawing on reverse )de. <br /> Signed X__ Title: Date: \ I <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by \ _ Date Area <br /> Pit or Grout Inspection by Date Final Inspection by ry\ « _ Date <br /> 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. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> CK <br /> . EH 13-21(REV.t,nSlILII C�/l Y�l 'r4 <br /> EH 1420 1 <br />