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APPLICATION FOR PERMIT a1 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> D �V` <br /> 7601 E. <br /> HAZE' <br /> 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 �/Nom/ /$ j J� City J715 <br /> Lot Size PM <br /> Owner's Name Address Q ,�C-���-3 <br /> / 17 <br /> J - Phone <br /> Contractor-JLU/JP.r'' Address- 7? <br /> License No. Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT L7 DESTRUCTION D <br /> PUMP INSTALLATION ❑ • SYSTEM REPAIR ❑ OTHER ❑ <br />`. DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE t <br /> FOUNDATION AGRICULTURE WELL C OTHER WELD PITS/SUMPS .�}y <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well basing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing <br /> Ll Public LJ Other Specifications <br /> q��� � ❑ Delta Depth of Grout Sea! Type of Grout <br /> �rigation p([rt�Approx. Depth ❑ Eastern Surface Seal Installed by r <br /> Repair Work Done Type of Pump IA!/V H P ` <br /> State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') s <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ CommercialOther available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Water table depth <br /> T <br /> ype/Mfg CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well <br /> Method of Disposal <br /> Foundation Property Line <br /> - r <br /> `-LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED C1 Distance <br /> length/size <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPSNumber <br /> DISPOSAL PONDS ❑ <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> 1 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed - Title: r.J � 7 <br /> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> > Date I ll Area <br /> Pit or Grout Inspection Date e <br /> Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 635-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton,Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTEDPCK H RECEIVED BY DATEPERMIT'NO. <br /> + EH t3-24{REV.t i w sy `- <br /> EH,42a t�� l o , �__J2. <br /> � . <br />