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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES ('YEAR FROM DATE ISSUED k <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 (l5 110 6�atz/vied City Lot Size PM <br /> Owner's Name /.�I Aez Address 7 !!//�4 a � Phone <br /> t <br /> r <br /> Contractor Address) License No, Zd Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 94--' 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 /> P-tro-mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F) Public ❑ Other 1 ❑ Delta Depth of Grout Seal Type of Grout <br /> ­ <br /> I 1 Irrigation ---Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump - H.P. /f2 State Work Done_ ' <br /> Well Destruction ❑ Well Diameter Sealing Material itop 50'1 <br /> Depth Filler Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ) REPAIR/ADDITION I i DESTRUCTION I ) (No septic system permitted if public sewer is <br /> available within 200 feet.) _ <br /> Installation will serve: Residence Commercial_ Other <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. Q Method of Disposal <br /> Distance to nearest: Well Foundation Property Line i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line iF <br /> a i <br /> SEEPAGE PITS f I Depth Size Number <br /> SUMPS Ll Distance to neatest: ..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: "I certify that in the performance of the work for which this permit is issuedr I shall employ persons subject to workman's compensa- <br /> tion lays of California." <br /> The applicant mus 1 for all re uir inspections. C plate drawing on reverse side. ' <br /> Sig d) Title:. Dater <br /> FOR DEPARTMENT USE ONLY -� <br /> Application Accepted byDate ' ` Area 1-Y, <br /> Pit or Grout Inspection by Date Final Inspection by r- _ Date <br /> Additional Comments: _ Fky <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 A am RM I V VIM E . <br /> Applicant - Return ail copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 9 t 4s3C9 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATliO N ALTI <br /> / n <br /> +.EH13-241pt:V.I/nsf R IVI I I /Z)r-IN], <br /> EH t4-28 S �� 3 <br /> r <br />