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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 —e�,Q . x City Lot Size PM <br /> Owner's Name _./"- Address Phone <br /> Contractor &Net Address (cense IV Phone,L <br /> TYPE OF WELL/PUMP: NEW WELL © 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 OTHE PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON N SPEGIFICATlONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing p <br /> l ❑ Domestic/Private ❑ Gravel Pack cy Type of Casing Specificationsp�3 <br /> M 7 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout _ �7 <br /> I I Irrigation ox. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ype of Pump H,P. State Work Done <br /> Weil Destruc ❑ Well Diameter Sealing Material {top 501 <br /> Depth Filler Material (Below 501 <br /> T PE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is <br /> available within 200 teet.l <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 C <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONOS ❑ <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 /> The applicant ust call for all required 1 pections. Complete drawing on girse side <br /> Signed X Title: Date: CJ ' AL3 f <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area 3 <br /> Pit or Grout Inspection by Date Final Inspection by ADate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ M nteca 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 INFO AMOUNT DUE AMOUNT REMITTED CASH CKf RECEIVED B DATE PERMIVNO. <br /> r EH 13-21(REV.I/x 5) S fg6a—, <br /> !� Q^7_5 <br /> EH 1428 ✓' ��ff „j •/i4 O / l 1 <br />