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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 N'D <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 istrict. <br /> I Job Addres �' ­�'c 7 City Lot Size PM <br /> Owner's Nam Address <br /> 4?y 17S Phone41 <br /> 3 <br /> i <br /> LContractor Address license No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION C] SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL sem, OTHER WELL — <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCT ICATIONS <br /> ❑ Industrial CC Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specifications <br /> f'l Public Cl Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Don Type of Pump H.P. State Work Done <br /> Well De Ion ❑ Well Diameter Sealing Material (top 50'i <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I T. .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: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments <br /> I PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS C I Depth Size Number <br /> SUMPS C1 Distance to nearest: 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 /> k employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> k 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 <br /> compensa-tion laws of California." <br /> Thea licant us all for all required ins tions. Complete drawing on reverse side. <br /> Signed X - Title: _ Date: <br /> - -�"7 <br /> F09 DEPARTMENT USE ONLY p, <br /> Application Accepted byDate —�1 Area <br /> I J <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> IAdditional Comments: / ,F <br /> F ❑ Stk 466-6781 d Lodi -36210 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmen al Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> r <br /> I <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH 1 <br /> 3-24(REV.1/851 ��UO Z;7-17-3 <br /> / �� <br /> EH 114.29 <br /> h �. <br />