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APPLICATION FOR PERMIT <br /> SAN JOAOUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL i ON AVE., STOCKTON, CA 00 <br /> Telephone (209) 466-6781 c13 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> (Complete in Triplicate) <br /> Application is hereby made to tha San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is W <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 city Lot Size PM <br /> Owner's Name 1•AAbtt0 - AddressPhone <br /> 3 i L k9'-,K y W 1AY - 5 7 -• (r�'y q <br /> Contractor's Name License No: Phone -�! <br /> I TYPE OF WELL/ IJMP:. '" ' NEW WELL O' WELL REPLACEMENT ❑ DESTRUCTION ❑ V� <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER E] W <br /> DISTANCE TO NEAREST.: SEPTIC TANK 5E LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRI TORE WELL OTHER WELL PITS/SUMPS <br /> INTENDED'U$E TYPE OF WELL PROBLEM AREA ONST CTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca DI f Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype Casing Specifications <br /> ❑ Public O Other ❑ Delta Depth o rout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Sea stalled by <br /> I Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> G Well Destruction ❑ Well Diameter Sealing Mate0al Itop 501 <br /> Depth Filler Material Welow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> r SEPTIC TANK ❑ Type/Mfg Capacity No.•Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER SED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> i <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 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 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 performanceof the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cal' -riia-" <br /> g <br /> The applicant sYcall forIl quire inspections. Complete drawing ori Fev rse side. �- <br /> Signed Title: Date: / � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by a " Date Z- Area <br /> lowON <br /> Pit or Grout Inspection byy Date Final Inspection by <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 INFO AMOUNT DUE AMOUNT REMITTED CASH }�R�ECEIVED BY y DATE PERMIT';NO. <br /> I +EH 13-24 1REV.10/831 f R� C11+ ��� + 4 ��� <br /> I EH 14.28 l <br />