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APPLICATION FOR IPERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 <br /> City � �U Lot Size PM <br /> Owner's Name Addresses tS3 .���• <br /> . F1one <br /> Contractor Address 352S-4 r <br /> TYPE OF WELL/PUMP: `license No. Q��Phone <br /> NEW WELL WELL REPLACEMENT Q DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER ❑ 1 <br /> SEWER LINES DISPOSAL FLD. PROP. UNE f <br /> FOUNDATION AGRICULTURE WELLOTHER WELL PETS/SUMPS <br /> ,INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ' <br /> D I ❑ Open Sottom ❑ Manteca Dia. of Well Excavation <br /> �j <br /> Domestic/PH Dia, of Well Casing <br /> �`�Gravel Pack ❑ Tracy Type of Casing 0eve, I <br /> ❑ Public ❑ Oth'ef�❑ Delta — Specifications <br /> Depth of Grout Seal <br /> Q Irrigation —_Approx. Depen B.Eastern Type of Gro t <br /> .� Surface Sea! Installed by <br /> Repair Work Done ❑ Type of Pump p-f� <br /> Well Destruction ❑ Well Diameter State Work Done <br /> --7 Sealing Material{ � '! <br /> Depth / Filler Material (Below 50'j __ <br /> TYPE PTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION Q DESTRUCTION ❑❑ (Na stem permitted if public sewer is <br /> Installation will serve: ce— Commercial! available within et,) <br /> Other <br /> Number of living units: Num bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> Q Type/Mfg Capacity No. Compartments f <br /> PKG. TREATMENT PLT, ❑ � + <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE Q No. & Length of lines <br /> FILTER BEDTotal length/size <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPSNumber <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <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 ofrCalifornia."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 <br /> tion laws of California." p y persons subject to workman's compensa- <br /> The appli an ust call for al re fired inspe ons. o late wing on reverse, e. <br /> Signed l <br /> iG+tl Date: <br /> FO AiRTMENT USE ONLY <br /> Application Accepted by 'gate` /`�}�_�X <br /> ."' d� Area <br /> Pit or Grout Inspection by F U v��fate <br /> " inal Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 Cl 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 <br /> INFO CAS RECEIVED BY DATE <br /> �j PERMIT'NO. <br /> EH 13-24(REV. /s 5) <br /> EH 1428 <br /> 11 �S <br />