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I <br /> APPLICATIOWFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE.,:STOCKTON, CA <br /> Telephone (209) 466-6781. L <br /> :,- In .-t <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. ^ .aid* fff.. . l r <br /> i Job Address i � ) # 7 City Lot Size PM <br /> µ�.. <br /> Owner's Name { •)�1 Address Phone <br /> 6� e <br /> Contractor� tf Addres License No. d Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL.RE LACEMENT ❑ DESTRUCTION '❑ <br /> � PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DIISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. . INE <br /> FOUNDATION AGRICULTURE WELL OTHER PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ECIFICATIONS <br /> ❑P I dustrial ❑ Open Bottom ._ ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑Domestic/Private ❑ Gravel Pack . ❑ Tr Type of Casing Specifications <br /> Type of Grout v1 <br /> El Public ❑ Other ❑ Delta Depth of Grout Seal yP <br /> { ❑ Irrigation proz. Depth. ❑ Eastern Surface_Seal Installed by' <br /> Repair ne ❑ Type of Pump H.P. tate VJd rk Done <br /> Well Destruction ❑ Well Diameter Sealing:Material sl•to��f W <br /> Depth Filler, Material (Below 50') _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR 4kDDITION ❑ DESTRUCTION INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence` Commercial— Other d <br /> Number of living units: Number of bedrooms <br /> depth <br /> table de <br /> Character of soil to a epth of 3 feets� Water P <br /> Capacity � No. Compartments <br /> SEPTIC TANK Type/Mfg 7 <br /> ' PKG. TREATMENT PLT. ❑ Method of Disposal <br /> l <br /> Disianc :to nearest: Well_ Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED LlDistance"to nearest: Well Foundation Proprty Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑p Distanceito nearest:- Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared th s application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I rules and regulations of the San Joaquin Local Health District. <br /> i 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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in tfle,perf&riKAfiV&Tf'he work'fo7 cfi this permit is issue I shall--Vr-iploy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus II or all required inspec;io 1s. Complete drawing on reverse side. ) j <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date � Area <br /> i 1 <br /> Pit or Grout Inspection by <br /> Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodir 369-3621 ❑ anteca 823-7104 .❑ Tracy 835-6385 <br /> '"` –AppGcan"Return ell copies_to: Environmental Health Permit/Services 1601 E.-M-25 on ve., .O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE' AMOUNTIAEM17 GK ,j '"# AECENED BY DATE PERM 'NO. <br /> ;+ EH.13-24 1REV.i/A 57 - <br /> EH 14-28 -- <br />