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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> IE Application is hereby made to the San Joaquin Local Health District for a permit to construct andlor install the work herein described. This application is <br /> made iri 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. �j <br /> I� <br /> .0� �G, /Y 1 1� vY Sx Cit �J`C !C�/� Lot Size <br /> Job Address r3�XSD PM <br /> T��r _ G,d V2?24 Address �d -1 <br /> Phone <br /> R411 )Orl �� --/433 <br /> Owner's Name ,�7 <br /> Contractor eA-n �r Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL LLD• PITS/SUMPS r <br /> w FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA RUCTION SPECIFICATIONS <br /> V <br /> ❑ Open Bottom El Industrial <br /> L1 Dia. of Well Excavation Dia. of Well Casing V i <br /> Type of Casing Specifications <br /> C] pomesuclPrivate ❑ Gravel Pack El Tracy 9 Type of Grout <br /> 1'l Public 5 Ot is Delta Depth of Grout Seal yp <br /> 1 Irrigation __Apptoxx. Depth ' l 1 Eastern Surface Seal Installed by <br /> rH P State Work Done— <br /> +' Repair Work D ❑ Type of Pump <br /> ! Well D uction ❑ Well Diameter Sealing Material (top 50'1 <br /> k Depth I Filler Material (Below 501 <br /> TYPE OF SFPTIC WORK: NEW INSTALLATION {] REPAIR { I-DESTRUCTION I (No septic system permitted if public sewer is <br /> Mailable within 200 feet.) <br /> Installation will serve: Residence _6 mmercial Other <br /> Number of living units: Number of bedrooms <br /> 0 Water table depth <br /> Character of soil to a depth of 3 feet: <br /> k "SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> ffff <br /> Method of Disposal <br /> PKG. TREATMENT PLT. ❑ . <br /> Distance to nearest: Well ~ -Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines _ <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well - Foundation Property Line <br /> SEEPAGE PITS I I Depth: Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation--- - ,Property Line <br /> DISPOSAL PONDS ❑ <br /> i 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 /> j employ any person in such manner as to become subject to workman's compensation laws of California." Contractors hiring or sub-contracting signature <br /> i certifies the following: "f 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 cal for all required inspectio Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout lnspec ' n Date Final inspection by Date <br /> Additional Comments: ' <br /> i ❑ Stk 466-6781 ❑ Lodi 369-3621 " 'E]Manteca -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 /> t �] <br /> i FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT N0. <br /> INFO }�� <br /> ♦ EH 13-241REV.i nsl - U S,v� C Ilp\ cc <br /> EH 14-26 - WSJ `J w <br />