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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209? 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. -7 �. . <br /> Job Address ; -t o` City Lot Size PM �. <br /> Owner's Nam ' 7 <br /> Address lit.— ���S k�` V e I Phone <br /> Contractor d I le f Address �� , License Nlt � Phone "a <br /> TYPE OF WELLIPUMP: NE WELL WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION, SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK I DDT._ SEWER LINES DISPOSAL FLD. PROP- LINE <br /> FOUNDATION I—S AGRICULTURE WELL OTHER WELL PITS/SUMPS/ o <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI N5 T,, , <br /> ❑ Industrial Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing +y` <br /> Domestic/Private ❑ Gravel Pack 171 Tracy Type of Casings Specifications ! <br /> ❑ Public F1 Otger Cl Delta Depth of Grout Seal r Type f Grput �'..1���—. <br /> I I Irrigation Approx. Depth l Eastern Surface Seal Installed by a - <br /> Repair Work Done ❑ Type of Pump S U "_ H.P. J-� State Work Done _ <br /> Well Destruction O Well Diameter Sealing Material itop 50'1 <br /> Depth Filler Material Welow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION 1 I DESTRUCTION I I (No septic system permitted it public sewer is <br /> available within 200 feet.I <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 /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments Ns <br /> PKG. TREATMENT PLT- ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> ' t <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line r <br /> SEEPAGE PITS 11 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 that the work will be done in accordance with San Joaquin county ordinances, state laws, an <br /> rules and regulations of the San Joaquin Local Health D3trict. <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 net <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 /> The applicant must cats for all required inspectiaos. Complete drawing on reverse side. <br /> Signe Title: Date: <br /> FOR DEPARTMENT USE ONLY 1 <br /> Application Accepted by Date < Area <br /> Pit oGrou Inspection by 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 AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> INFO <br /> / �/..{Q' f/'�JJ� f~ /rye f <br /> +.EH 17-21(REV.r/n b) (3�7 .J f U/ra ! �.+� ! f D �O —a <br /> EH 11-28 <br />