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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) 466-6781 <br /> S <br /> PERMIT EXPIRES TYEAR 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 />[ r <br /> Job Address Ile, 1~ City Lot Size <br /> Q�� fEM <br /> Owner's Name - !�fi" �PC(I~ Address �� T A_JPh Vy <br /> Contractor Address ?� %c+ License No, Phone <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 j <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of.Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l`1 Public Ll Other C1 Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation -Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Materia! (top 50') <br /> N <br /> Depth Filler Material (Below 501 <br /> r TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION LI DESTRUCTION l I (No septic system permitted if public sewer is <br /> available within 200 feet.) 1 <br /> Installation will serve:,,Residence Commercial_/Other <br /> Number of living units: —I-- Number of bedrooms <br /> Character of soil to a depth of 3 feet: F Water table depth <br /> SEPTIC TANK v ❑ Type/Mfg -L.I Capacity No. Compartments <br /> PKG. TREATMENT PLT. © Method of Disposal, <br /> Distanceto nearest: Well ' Foundation Property Line <br /> ,!( <br /> LEACHING LINE No. & Length of lines -� d Total length/size r� <br /> FILTER BED ❑ Distance to nearest: WeII Foundation Property Line <br /> SEEPAGE PITS I I Depth _ Size_ __ Number -. <br /> SUMPS 0 Distance to nearest: WeII 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'bf'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 1566ed,I,shPll employ persons subject to workman's compensa- <br /> tion laws of California." '1.i <br /> The applicant must call for I require 'nspections. Complete drawing on reverse side. <br /> Signed Date: <br /> FOR DEPARTMENT USE ONL .,{�� t <br /> r <br /> rT. <br /> Application Accepted by Date : Area <br /> Pit or Grout Inspection by �J +Date Final lnspecti ";� yDate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O Box 2009, Stk, CA 95201 <br /> FEE CK 4 <br /> INFO AMOUNT DUE AM CASHCASH RECEIVED BY DATE PERMIT NO. <br /> r EH1a-241REV.tins) !ZQ /©� k9 � <br /> EK 114-25 �r/_ 1 <br />