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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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size/a:�01 PM 7 <br /> Owner's Name- Address , .4�i'ise Pho <br /> Contract '.� 5,[�.�/ L2l�-�c�/1�AddresA No. Phan ` <br /> TYPE OF WELL/PUMP: NEW WELL O WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES 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 /> Q Domestic/Private ❑ Gravel Pack 13Tracy Type of Casing Specifications <br /> M Public n Other Ll Delta Depth of Grout Seat Type of Grout <br /> I i Irrigation --Approx. Depth t I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction (71Well Diameter Sealing Material (top 501 i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITIONX DESTRUCTION I 1 (No septic system permitted if public sewer is <br /> available within 200 feet-) i <br /> Installation will serve: R sidence Commercial they <br /> Number of living units Number of bedroom ` <br /> Character of soil to a depth of 3 feet: Water table depth is , <br /> SEPTIC TANK JMS17` Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> I� <br /> l Distance to nearest: Well Foundation Property Line <br /> I <br /> i <br /> LEACHING UNE No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS <br /> l SUMPS Distance to nearest: Wep Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> f <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, ar <br /> rules and regulations of the San Joaquin Local Health District. I <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 /> The applicant must call for all required ' s do . Complete awing on reverse side. <br /> Signed Title:C Date: <br /> ti <br /> FOR DEPARTMENT USE ONLY <br /> .P <br /> Appli ation Accepted by Date Area _ <br /> P' r rout Inspection by Final Inspection by { �Date <br /> Itlonal11 Stk 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 CK 0 RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> + EH13-24{REV.i/nsl , <br /> EH 14-26 70 <br /> r <br />