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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 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 applitcation is <br /> made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for welt//pump and the Rules and Regulations of the San Joaquin <br /> Local Health District i";` t j <br /> Job Address �� p �JFar S'�,C_ ; " Ci of Size �� PM <br /> Owner's Name Address _�� i !��/Srr' �. Phone <br /> Contractor T'Q` Address �% icense No. Phone <br /> TYPE-OF WELL'/PUMP: NEW WELL ❑ "`WELL REPLACEMENT ❑ DESTRUCTION ❑ , <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LJOTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES,�'f DISPOSAL FLD. 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 Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Sear Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by'-, 4 <br /> Repair Work Done ❑ Type of Pump' H.P. State Work Done <br /> v <br /> Well Destruction ❑ Well Diameter, v uSeeling-Material (top 501 r <br /> Depth Filler`Material (Below 501 <br /> TYPE OF.SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> 1 I available within 200 feet.) <br /> Installation will serve: Residence L< Commercial— Other _4 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: � 0 _ Water table depth �d <br /> SEPTIC TANK Type/Mfg I ,e� �!- j Capacity No. Compartments.l' <br /> PKG. TREATMENT PLT. ❑ /, Method of Disposr( <br /> Distance to nearest: Well Fpundation__.. - Property LineQl <br /> R♦ 4L� <br /> LEACHING LINE "o. & Length of lines , - ��� -------- -- Total length/size ' <br /> FILTER BED ❑ Distance to nearest: Well <br /> ,Foundation Property Line <br /> x t <br /> SEEPAGE PITS Depth c 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 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 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 /> J.. <br /> The applica-`:must call-for-all-required-inspections Gomplet drawing-on reverse-side. <br /> Signed X Title: Date: <br /> F EPAIRTMENT USE ONLY <br /> } I <br /> Application Accepte y Date - �� 'Area �9 <br /> it Grout Inspe ' by- Date t Z�l'7_. iFinal Inspection byti Date <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354385 v <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton AveA} P.O. Box 2009, Stk., CA 95201 <br /> FEE { <br /> INFO AMOUNT DUE .� AMOUNT REMITTED CK RECEIVED BY DATE � PERMIT'N0. <br /> + EH13-24{REV.1/8 5) <br /> EH 14-26 <br />