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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 <br /> PERMIT EXPIRES T 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 5 so, City Lot Size PM <br /> Owner's Nam Address �`~�" "�- Phone <br /> s <br /> Contract Address License N Phone <br /> TYPE OF WELL/PUMP: v NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION 0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ ! -„ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. -4_PROP. LINE <br /> _- -FOUNDATION AGRICULTURE WELL OTHER WELL-------I:. PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS r` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing = <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal _ / Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed_by m <br /> Repair it Work Done ❑ T p <br /> Type of Pum H.P. " State Work Dane <br /> Well Destruction ❑ Well Diameter Sealing Material (top•501, <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION I 1 'DESTRUCTION-IFI Wo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence K Commercial_ Other f <br /> Number of living units: Number of drooms •; ` <br /> Character of soil to a depthof3 feet: f Water table depth (� <br /> SEPTIC TANK /6- Type/Mfg Capacity O No. Compartments <br /> PKG. TREATMENT PLT. ❑ / ,- -- - e- Method of Di"?osal <br /> Distance to nearest: WellD Foundation Property Line <br /> r � , I <br /> LEACHING LINE 'Ie No. & Length of lines LS `J d Total length/size` <br /> FILTER BED ❑ Distance to nearest: Well ` Foundation � Property Line <br /> SEEPAGE PITS 1l 1 Depth Size K Number <br /> SUMPS X Distance to nearest: Well,._,_.__ Foundation <br /> _/40/ Property Line � <br /> DISPOSAL PONDS ❑ <br /> 1 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 Di%trict. <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,l shall employ persons subject to workman's compensa- <br /> tion laws of California." . <br /> The applicant mu all for al uire inspections. Complete drawing on reverse slide. <br /> Signed Title: V. 6 T Date:03-0io-K 197 <br /> FOR DEPARTMENT,USE ONLY <br /> Applica'on Accepted by Date' Area <br /> _2*1511rout Insp 'tion by Dato �r inal Inspection by 7:4 _ ,­f-� Date-L' <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED BY DATE PERMIT-NO. <br /> +.EH13-24118 1 i x s 1 f <br /> EH 14.28 <br />