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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 I 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 Ryles and Regulations of the San Joaquin <br /> Local Health Diissttrict. <br /> Job Address U Z / �` Ci �►� Lot Size ` PM <br /> Owner's Name Address S24 t /z riu Phone / l -2-'/27 <br /> Contractor , f Address 74License No 6 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> : PUMP INSTALLATION ❑ -SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES' DISPOSAL FW. PROP. LINE <br /> FOUNDATION , AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca , bia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy �` Type of Casing Specifications <br /> ❑ Public ❑ Other 0 Delta . Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depthi ❑Eastern _ Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Fi Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AIR' 'DDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> iavailable within 200 feet.) <br /> Installation will serve: Residence Commercial_ Others �Ct tar" <br /> Number of living units: Number of bedrooms _ ' <br /> Character of soil to a depth of 3 feet: WateF',table depth_ �Jr <br /> SEPTIC TANK PK Type/Mfg Capacity J!6k1e6 No. Compartments <br /> PKG,. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE EE/ No. & Length ot,Iines Total length/size D <br /> FILTER BED ❑ Distance [S nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth a _Size 3 �1 Number 3 <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ / <br /> 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 /> employ arty 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 thatih 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." I <br /> The appJlcant must call for all required inspections. Complete drawing on reverse side./�us/ <br /> Signed X 44 4.d � ll��i� Title: Date: -7- <br /> OR DEPART E SE ONLY <br /> Application Accepted by Date e4 v Area <br /> Pit or Grout Inspection by - Date Final Inspection by Date 7 d <br /> Additional Comte a ts: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83 6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA` 5201 <br /> FEE INFO "AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY 1-7DATE PERMIT'NO. <br /> Eti 73-24{REV.t/e 51 �p,�f b 9 I&S <br /> ^b5�EH 1426 1 JL? <br />