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C APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> ` 1601 E. HAZEL T ON AVE., STOCKTON, CA 1 <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. e <br /> City Lot Size PM <br /> Job Address f <br /> Owner's Name we LL, I_ — Address Phone <br /> f eA9 + Address J 40 _License No. 'J+6_oPhone <br /> Phone <br /> 6S' u <br /> Contractor <br />` TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT ❑ DESTRUCTIO <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR FI OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WE OTHER WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial <br /> El Bottom ❑ M a Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private d Gravel Pack Tracy Type of Casing Specifications <br /> III n Public nOther Cl Delta J Depth of Grout Seal Type of Graut <br /> I Irrigation ppr6x. Depth I I Eastern Surface Seal Installed by <br /> I <br /> Repair Work Done -Type of Pump H.P. State Work Done <br /> Well DestnX ton ❑ Well Diameter Sealing Material atop 501 <br /> I Depth 'I Filler Material (Below 501 <br /> i TYPE OF SFPTIC WORK: NEW INSTALLATION ('i REPAIR/ADDITION I 1 DESTRUCTION I iNo septic system permitted it public sewer is <br /> I _ available within 200 feet.) <br /> Instaliation 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 /> Y kI <br /> LEACHING LINE ❑ No. &Length of lines _ Total length/size <br /> FILTER BED ❑ Distance to nearest: ' Well ti Foundation Property Line <br /> 4 <br /> SEEPAGE PITS I I Depthal Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> t DISPOSAL PONDS ❑ IT <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 follo ' g. " ertify 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 Calif mi ' <br /> The applicant m st II required inspections. Complete drawing on reverse side. p_7 <br /> Signed X Title: A Date: l! <br /> FOR DEPARTMENT USE ONLY <br /> { Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final inspection by r Date <br /> ' t <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 H RECEIVED By DATE PERMIT-NO. <br /> INFO <br /> F ♦ EH 13-24 1REV.1 8 57 <br /> EH 14-26 <br /> k <br />