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S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Au <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 /> 2/� <br /> Job Address 649 <br /> City v Lot Size PM <br /> Owner's Name Address � &e�atl� Phone <br /> Contractor Address Y License No. <br /> Phf— E <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTI SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION <br /> AGA IC LL OTHER PS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA UCTIO ICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ ca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Domestic/Private LJ Gravel Pac ❑ Tracy Type of Casing ications ~ <br /> ❑ Public ❑ O ❑ Delta ' <br /> Depth of Grout Seal Type of Grou <br /> ❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work e ❑ Type of Pump H p l <br /> State Work Done, r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') # <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONavailable within 200 feet.I(No septic system permitted if public sewer is <br /> ' <br /> Installation will serve: Residence— Commercial— Other Jr <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT- ❑ <br /> Y _- Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE •❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ ' Depth Size Number <br /> SUMPS ❑ Distance to nearest Well Foundation Property p r[y — <br /> Line--DISPOSAL PONDS ❑ <br /> 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. I <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 ust call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: 1 <br /> Date: <br /> FOR DEPARTMENT USE ONLY ,-Q <br /> Appli ion Accepted by Date rea�`U� _ Q>� <br /> �r� <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> LLIX <br /> Additional Comments: I ► <br /> ❑ Stk 466-6781 F) Lod' 369-3621 ❑ Manteca 823-7104 C1 Tracy 835-6385 <br /> Applicant- Return all copies' <br /> opies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> f <br /> FEE AMpUNT DUE AMOUNT REMITTED <br /> INFO CK RECEIVED BY DATE PERMIT NO. <br /> a EH 13-24 IREV.t/x 51 0(� V✓ a� ) /may <br />