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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 /> 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 Dis�tric�t. {' <br /> Job Address M,&,,e,,, 1— city i Ll <br /> Size-21 <br /> r - S ,S <br /> Owner's Name "�r� Address PhaneContractor dress 1 /V License No , Phone i _22 2- <br /> TYPE <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT C DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM AIR C OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK EWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION A RICULTUR ELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WEXt8rn <br /> EA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open BottomDia. of Well Excavation Dia- of Well Casing <br /> 0 Domestic/Private ❑ Gravel PackType of Casing Specifications <br /> f- Public Cl OtherDepth of Grout Seal Type of Grout _ <br /> Irrigation _.Approx. DSurface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump State Work Done_ <br /> Well Destruction ❑ Well Diametera g Material (top 50�}Depther aterial (Below 501 <br /> TYPE OFSEPTIC WORK: NEW INSTALLATION i REPAIR/ADDITION I : DESTRUCTION i 1 (No septic system permitted if public sewer is <br /> '/ available within 200 feet.) <br /> Installation will serve: Residence= Commercialther r <br /> Number of living units: Number of bedrooms] <br /> Character of soil to a depth of 3 feet: Water table depth �{ <br /> SEPTIC TANK !:1 Type/Mfg Capacity.2l)� No. Compartments <br /> PKG. TREATMENT PLT, i=1 Method A Disposal <br /> Distance to nearest: Well yU/Foundation_ 4:_ Property Line 40IF— <br /> U <br /> LEACHING LINE ❑ No.& Length of lines Total length/size <br /> FILTER BED C Distance to nearest: Well oundation Property Line <br /> (SoSEEPAGE PITS I Depth Size Number ,- <br /> SUMPS ❑ Distance to nearest: Wef Foundation — Property Line _ <br /> DISPOSAL PONDS O <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 Di1trict. <br /> Home owner or licensed agent's signature certifies fhe following: "I certify that in the performance of the work for which this perrrdt 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 applican ust call for quired 1 pections. Complete drawing on reverse side. /f <br /> Signed 1 Title: Date: !/r.2 IK_ <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> gor Grout Inspection by Date final Inspection by Date/7�1 � <br /> LI <br /> Additional Comments: — (/ <br /> ❑ Stk 466.6781 CI Lodi 369-3621 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk„ CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO, <br /> INFO CASH <br /> ..EH1 <br /> 3.2401EV.t/xai <br /> EH 1428 t�� <br />