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` s <br /> } APPLICATION FOR PERMIT ' <br /> f 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 /> k. <br /> Job Address �R �' ' City of Size PM <br /> Owner's Name Address - ' Phone 5~ <br />` Contractor Address=���I _ �f/Z-License No:/ O 'Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINE .DISPOSAL FLD. PROP. LINE - - <br /> - i <br /> FOUNDATION AGRICULTU WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D.Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> FI Public 1-1 Other fl Delta Depth of Grout Seal " Type of Grout _ <br /> I I Irrigation _.-Approxi Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth ` _,Filler Material (Below'501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 111 REPAIR©DDITI l I DLST CTION INo septic system permitted if public sewer is <br /> Alavailable with' 200 feet. <br /> Installation will serve: Residence Commercial_ Other <br /> r <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet Water table depth r +� <br /> r <br /> SEPTIC TANK ❑ Type/Mfg Capacity-----------:— No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distanc 'to-nearest; ­-WeIl___. Foundation Property.Line { <br /> ,I <br /> LEACHING LINE ❑ No. & Length'df"tines Total length/size <br /> FILTER BED "❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS ❑ Distanceto nearest: Well Foundation Property Line <br /> DISPOSAL PONDS' ❑ <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 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." <br /> The applicant ost tali foraluire;d;Znspe ons. Complete drawing on reverse-side. f (� <br /> Signed X Title: _ ic,�r ,�_ -- _ Date: 1.2—3� U <br /> FOR,DEPARTMENT USE ONLY <br /> Application Accepted by +:5--, Date 0, Area <br /> Pit or Grout Inspection by Date Final Inspection byr Date <br /> Additional Comments: 0 <br /> ❑ Stk 466-6791 ❑ Lodi 339-3621 ❑ 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 /> j — <br /> FEE INFO AMOUNT DUE' AMOUNT REMIT-TED ED C SH CK RECEIVED BY DATE PERMIT'NO. <br /> r.EH 13-24 IREV.1/0 51 <br /> EH 14-2e _ T <br />