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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) 496-679L ,EJ -1�1.. ice' <br /> i;PERMIT EXPIRES 'f YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) �a U <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 E <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 �TSize PM <br /> yg6?! Lpt <br /> Owner's Name <br /> Address 7 �J1 L/lJJit�- Phone <br /> Contractor 4Address License No. Phone <br /> TYPE OF WEL /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION:❑ SYSTEM REPAIR ❑ -" OTHER ❑ •- <br /> DISTANCE TON EST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> AGRICULTURE WELL OTHER WELL—. PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBL CONST NS <br /> 11 Industrial ❑ Open Bottom [I Man Dia. Excavation Dia. of Well Casing <br /> t Type of Casing Specifications <br /> ❑ DomesticlPrivate ❑ Gravel Pack,-, Tracy yp 9 - <br /> t"1 Public ❑ Other I ❑ Delta Depth of Grout Seal <br /> Type of Grout _ <br /> I I Irrigation pprox.':Depth I I Eastern Surface Seal Installed by— <br /> Repair <br /> y Repair Work Done ❑ ype of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth - Filler Material {Below 50') - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIRIADDITION 1J DESTRUCTION (No septic system permitted it public sewer is <br /> vaiiable within 200 feeLl <br /> Installation will serve: Residence�� Commercial— Other <br /> Number of living units: Number of bedrooms / © �T <br /> Character of soil to a depth of 3 feet:`I bo Water table depth Cd <br /> SEPTIC TANK ❑ TypelMfg 1 Capacity�Zdd 6/1/- No. Compartments �- <br /> PKG. TREATMENT PLT. ❑ 1 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No- lir Length of lines Total length/size <br /> FILTER BED ❑ Distance to_nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth I Size _ Number <br /> SUMPS c Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 f <br /> rules and regulations of the San Joaquin Local Health Di§trict. <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." � t <br /> The applica must c r rbd ' sped omplete drawing on reverse side. <br /> Signe X Title: Date: <br /> FDR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> 1 <br /> Additional Comments: a T n �T � - <br /> ❑ Stk-•-466-6791 L dL 3621• lent ca 823-7104 - ElTracy 835-699 <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 CASH RECEIVED BY DATE PERM17'NO. <br /> INFO <br /> ­EH 13-24 ipEV.1/n5) S <br /> EH 14-26 } <br />