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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 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. <br />Job Address / <br />' � I City "�-�� Lot Size PM <br />Owner's Name 4 OK I /746 -MO- Address 1 < < I Phone 9 /JcU�a <br />Contractor's Name I: :TJ(e, License No. �V-[ Q-/ v Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT El DESTRUCTION ❑ <br />PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br />DISTANCE TO NEAREST: SEPTIC TANK 1 f SEWER LINES DISPOSAL FLD. PROP. LINE <br />-FOUNDATION- - AGRICULTURE WELL• OTHER WELL PITS/SUMPS .___ <br />INTENDED USE <br />❑ Industrial <br />Domestic/ Private <br />❑ Public <br />❑ Irrigation <br />fi <br />Repair Work Done <br />Well Destruction ❑ <br />TYPE OF WELL <br />PROBLEM AREA <br />CONSTRUCTION SPECIFICATIONS <br />❑ Open Bottom <br />❑ Manteca <br />Dia. of Well Excavation <br />❑ Gravel Pack <br />❑ Tracy <br />Type of -Casing <br />❑����Other <br />&A/ pprox. Depth <br />El Delta � <br />El Eastern <br />Depth of Grout Seal <br />Surface -Seal .Installed by. <br />Type of Pump _ H. P. ' •:;State-Work•Done <br />Well DiameterSealing Material [top 501 r <br />Depth Ju� t Filler Material (Below -50'.) - <br />E OF SEPTIC,WORK: NEW INSTALLATION ❑, REPAIR/ADDITION ❑ <br />Installation will serve: Residence _ Commercial — <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: <br />SEPTIC TANK ❑ Type/Mfg <br />PKG. TREATMENT PLT. ❑ <br />Other ►*` <br />Capacity_ <br />Distance to nearest: i Well Foundation <br />LEACHING LINE ❑ No. & Length of lines <br />FILTER BED ❑ Distance to nearest: Well Foundation <br />SEEPAGE PITS, ❑ Depth Size <br />SUMPS ❑ Distance to nearest: Well <br />DISPOSAL PONDS ❑ <br />Foundation <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />(No septic system permitted if public sewer is <br />available within 200 feet.) , <br />Water table depth <br />No. Compartments <br />Method of Disposal <br />Property Line <br />Total length/size_ <br />Property Line <br />Number P <br />Property Line <br />L_l <br />I 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." Contractors hiring or sub -contracting signature <br />certifies the following: "I certify that in 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." <br />The applicant must call for all required inspections. Complete drawing on reverse side. <br />i <br />SignedY)fTitle: Date:f JF <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by _�C ' _ ! _ Date Area <br />Pit or Grout Inspection by Date ' Final Inspection by /� Date 1/ <br />Additional Comments: /I <br />❑ Stk 466 -Ml ❑ 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 />INFO FEE AMOUNT DUE AMOUNT REMITTED CASH 0 RECEIVED BY DATE PERMIT"No. <br />�r r <br />+ EH 1324 (REV. 10l831 S U i/z %� —, <br />EH 1416 <br />