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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 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 District. �jzgCr <br /> " <br /> s ����--- <br /> Job Address /� �,�i/ _- City,5/0G' �O_t7 Lot Size PM <br /> Owner's Name Ly t'S / t rum Address �I, Phone 4&6,&36 <br /> Contractor ,�G(�� – Address License No. 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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation i Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ' TypeofCasings - ' s ti 1Specifications <br /> ❑ Public ❑ Other ❑ Delta' Depth-of_Grout Seal. _ Type of Grout <br /> ❑ Irrigation- pptox. Depth ❑ 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 Filler Material IBelow 50') a <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION Wo septic system permitted if public sewer is t <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial— Other <br /> Number of living units: ;Number of bedrooms r <br /> Character of soil to a depth of 3-feet: _ _ Water table depth <br /> SEPTIC TANK % ' Cl Type/Mfg r Capacity No. Compartments <br /> 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 tD nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and$haYthe 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'F _ <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: "t certify that in the performance of the work for whichrthis permit is issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m call for all required in ctions. Complete drawing on reverse side. ` <br /> Signed Title: Date: 7—k,;7 <br /> FOR DEPARTMENT-USE ONLY <br /> Application Accepted by Date Area D <br /> Pit or Grout Inspection by Date Final Inspection Date 6 <br /> Additional Comments: M-1 1 �� r <br /> ❑ Stk 466-6781 ❑ Lodi 36.9-3621 ❑ 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 CK RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24 1REV.1/e 5 <br /> EH W28 3 i �/� <br />