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I APPLICATION FOR PERMIT <br /> f A SAN JOAQUIN LOCAL HEALTH DISTRICT � <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ID <br /> Telephone 1209) 466-6781 <br /> PERMIT EXPIRES 9 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, J}� <br /> Job Address A w,r 1. zc A) City Lot Size PM <br /> t <br /> Owner's Name , <br /> ddress Phone <br /> Contractor NS �� Address' U-<n License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION } <br /> 4 'e,_— PUMPINST;kEaTION--`—SYSTEM'REPAIR_❑ <br /> pISTANCEfTO NEAREST: SEPTIC TANK ; �• SEWER LINES DISPOSAL FLD. PROP. LINE <br /> / FOUNDATION -. ,AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> PE OF WELL PROBLEM AREA COSTRUCTION SPE'GIFICATIONS <br /> INTfNDED USE i___TY <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia_ of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private 0-Gravel.Pack— LI TracyType of Casing *""�`',! Specifications�r <br /> fil Public i1 Other Cl Delta Depfh..of-•Grout 5eali Type of Grout <br /> f i I.Ifrictation # _ Approx. Depth i I Eastern Surface Seal Ins ailed by - <br /> } f 04 <br /> Repair Work Done ❑ Type of Pump _. H.P. I Slate WorkD ne G <br /> kI Weil Destruction iWell Diameter Sealing Material (top <br /> i <br /> Depth Filler Material (Below "= t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] REPAIR/ADDITION l 1 DESTRUCTION l 1 (No septic system permitted if public sewer is <br /> available within 200 feed <br /> lnstallation will serve: Residence Commercial_ Other <br /> i I r s <br /> I Number of living units: Number of bedrooms t <br /> j3 <br /> f( Character of..soil'to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments t*t <br /> ` PKG. TREATMENT PLT. LlMethod of Disposal I <br /> t _ <br /> I i <br /> Distance to nearest: Well Foundation Property line � <br /> ! I I R <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> SEEPAGE PITS I I DepthI Size _ Number <br /> SUMPS i Y Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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. i <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the±nrofk for which this permit is issued, I shall not <br /> employ any person in such manner as to became 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." I L <br /> The applicant mu r quired i Complete drawing on raver side. <br /> Signed X , Title: Date: �� a <br /> FOR DEPARTMENT USE LY <br /> Application Accepted by CJIN Dat Area <br /> Pit or Grout Inspection by Date Final Inspection by Rate <br /> I Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ 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 /> FEE AMOUNT DUE: AMOUNT REMITTED CK RECEIVED 8 DATE PERMIT•NO. <br /> i INFO 2 CASH <br /> E +�EH 13-24(REV.r/n 51 <br /> 1:H 14-2a A"IJ <br />