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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT a.Q ,�I ? <br /> 1601 E. HAZELTON AVE., STOCKTON, CA �* ' <br /> Telephone (209) 466-67$1 a gut . <br /> ro <br /> ..- <br /> PERMIT EXPIRES 1 DATE ISSUED-YEAR FROM <br /> [Complete in Triplils ate);; .� . <br /> I '� 1rr <br /> I 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:„ F <br /> �. X 1.a C1 <br /> Job Address / � City � Lot Size SPM <br /> � V 1E <br /> Owner's Name ddress f Phone <br /> Contractor fi Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ TRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ DEOTHER 11DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES E€ DISPOSAL FLD. PROP. LINE <br /> I FOUNDATIONAGRICULTUR li OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF.WELL PROBLE CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Ot ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _ Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Do ❑ Type of Pump H.P. ' State Work Done_ <br /> F. <br /> Well Destruction ❑ Well Diameter Sealing Material atop 501 <br /> ,r <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted if public sewer is <br /> it available within 200 feet.) <br /> Installation will serve: Residence t Commercial Other <br /> Number of living units: Number of bedrooms <br /> 'i Character of soil to a depth of 3 feet: ! Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments —1 <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I# <br /> Distance to nearest: Well Foundation Property Line <br /> <. <br /> # LEACHING LINE ❑ No. & Le �ngth of lines Total length/size, <br /> i FILTER BED ❑ Distance to nearest: Well foundation Property Line <br /> SEEPAGE PITS ❑ Depth' Size II Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> j DISPOSAL PONDS ❑ .l <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 /> r rules and regulations of the San Joaquin Local Health District. _ e <br /> Home owner or licensed agent's signature certifies the following: :'L 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 subcontracting 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 mu all for all required inspections. Complete drawing on reverse side. <br /> n -Signed X Title: /_.__C! Date: 7 �! <br /> J'l n <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area ®A. <br /> 7 7 <br /> E Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> F-1 Stk 466 67$1 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy -835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit Services_1 1 E. azel n Av ., P 0. Stk., CA 95201 r <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24(REV.t i F,5) 3� r � <br /> EH 14.24 cc..�� _ <br />