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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 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 1:��� f� �C�fi. ���� City- Lot Size �_{ PM <br /> Owner's Name Address ' Phone <br /> Contractor Address License No._ - Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALbkTJ,0N ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A ULTURE WELL OTHER WELL SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA STR CIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca ia. of xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack, ❑ Type of Casin Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation rox. Depth ❑ Eastern Surface Seat Installed by <br /> Repair Work Done ype of Pump H.P. State Work Do ! <br /> Well Destruction ❑ Well Diameter Sealing Material itop 501 <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_ Other <br /> Number of living units: Number of bedrooms U1 <br /> Character of soil to a dept 3 feet: W e depth <br /> SEPTIC TANK El Type/ Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well oundation Property Line <br /> ii <br /> L <br /> LEACHING LINE ❑ No. & Len Ines Total length/size <br /> FILTER BED ❑ D' ce to nearest: Well Fou In Property Line <br /> 'S <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑!' Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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 lawsr 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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: 0 Date: 2-761-97 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �`� � / Area �✓ <br /> Pit or Grout Inspection by Date Final Ins tion by Da <br /> Additional Comments:,, Ag" Di <br /> El Stk 456-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ T cy 835-5385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> f <br /> FEE <br /> I <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT`NO. <br /> + EH1324rREV.r/es1 3- o �12b g �a <br /> EH 1428 97-2 <br />