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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1 1601 E. HAZEI_TON 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 Y w City Lot Size PM <br /> Owner's Name t 6 Address Phone <br /> Contractor's Name wf� License No. cats+77aPhone�ZX7 <br /> j TYPE OF WE L/PUMP.. NEW WELL WELL REPLACEMEN DESTRUCTION El�I�d PUMP WSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ / <br /> DISTANCE TO NEAREST: SEPTIC TANK ` SEWER LINES �ils7� DISPOSAL FLD.2t:O PROP. LINE ld <br /> FOUNDATIONS AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATI I <` <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> k—omestic/Private _,'?513ravel Pack acy Type of Casing Specifications ` <br /> ❑ Public - ElOther ❑ Delta Depth of Grout Seal /T1 Type of Groyt <br /> El Irrigation' <br /> ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done 0 Type of Pump H.P. State Work Done <br /> F -' <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <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 /> 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 /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t <br /> } LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well e!n__&ndat1on— Property Line <br /> i <br /> r SEEPAGE PITS ❑ Depth Size Number q ,r <br /> SUMPS ❑ X Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ w <br /> k 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 applica mu t call for re ins pec' ns. plate drawing-on reverse-side:'""`"""'i <br /> / _ �!Q <br /> Signed Title:^ � fi(/I�f l Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area &7 _ <br /> Pit or Grout Inspection'by Date Z Final Inspection by Date 415 <br /> Additional Comments- <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82:3-7104 ❑ 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 /> IFEE <br /> NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13.241REV.W83} C7© _ 9�5/$y CaL,-1�.s <br /> EH 14-28 <br />