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APPLICATION FOR PERMIT <br />SAN JOAQUIN LOCAL HEALTH DISTRICT <br />1601 E. HAZELTON 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 H aith District. <br />AZ 41 <br />Job AddressftA4 1/4! �� �i��""ts Cit Size PM <br />r� <br />Owner's Name — Address Phone <br />Contractor's Name V 1 111 117 4 No. f Phone .Zf ` <br />TYPE OF WELL/PUMP: i NEW WELL ❑ WELL REPLACEMENT ❑ I DESTRUCTION ❑ <br />PUMP5NST ELATION ❑ SYSTEM REPAIR ❑ OTfiER ❑ <br />DISTANCE TO NEAREST: SEPTIC TXhI1 SEWER LINES DISPOSAL FLD. _ PROP. LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL _ PITS/SUMPS <br />ILv i ENDED USE <br />Industrial J <br />Domestic/ Private <br />Public <br />Irrigation <br />pair Work Done <br />all Destruction <br />TYPE ;O f *ELI�Lt <br />❑ OperJEfo4on1JV <br />O Gravel Pack <br />❑ Other <br />] <br />�pprox. Depth <br />Type of Pump <br />Well Diameter <br />Depth <br />TYPE OF SEPTIC WORK: NEW INSTALLATION <br />AREA CONSTRUCTION SPECIFICATIONS <br />❑ Manteca <br />Dia. of Well Excavation <br />❑ Tracy <br />Type of Casing <br />❑ Delta <br />Depth of Grout Seal <br />❑ Eastern <br />Surface Seal Installed by <br />H. P. <br />State Work Done _ <br />Sealing Material (top 501 <br />Filler Material (Belo'; <br />❑ REPAIR/ADDITION DES7 <br />Dia. of Well Casing <br />Specifications <br />Type of Grout <br />(No septic system permitted if public sewer is <br />available within 200 feet.) I <br />I <br />Installation will serve: Residence — Commercial -L Other <br />Number of living units: Number of bedrooms <br />Character of soil to a depth of 3 feet: Water table depth _ <br />SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br />PKG. TREATMENT PLT.❑ Method of Disposal <br />Distance to nearest: Well Foundation � Property Line <br />ACHING LINE ❑ No. & Length of lines <br />.tER BED ❑ Distance to nearest: <br />­- ". <br />SUMPS ❑ <br />DISPOSAL PONDS ❑ <br />hereby ceq that I have' <br />rules and r gu ations of the <br />Home owner or.ilansed ag <br />employ any personiin„suci <br />certifies the following:;el <br />fionlaws oi"Califb . is!�� <br />' <br />Tie applicant t c for <br />• <br />Signed' <br />Depth :J` d <br />Distance to nearest: <br />Total <br />Foundation Property Lin <br />Number <br />Foundation Property Line <br />0. this application and that the work will be done in accordance with SanpJoaquin county ordinances, state laws, and <br />;Aquin Local Health District. <br />(nature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br />as to become subject 40 workman's compensation laws of Cal#6rnia." Contractor's hiring or sub-contractiprg signature <br />t in the performance of the work for which this per�sjssatd, I shall employ persons subject to workman's compensa- <br />it n pections. Compt drawing on side. f/ <br />Title: Date:. y " <br />FOR DEPARTMENT USE ONLY <br />f <br />Application Accepted by <br />Date Area <br />Pit or Grout Inspectionrb .. ate r i Final inspection by Date <br />Additional Comments: � d � <br />ti I <br />St 6781 ❑ Lodi 369-3621 C1Mant ca 823-7104 El Tracy 836,M <br />Applicant - Return all copies to: Environmental Health Permit/ Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />+ EH 13-24IRFV. 10183 <br />EH 14.26 <br />FEE <br />INFO <br />AMOUNT DUE <br />AMOUNT REMITTED CK <br />CASH <br />RECEIVED BY <br />DATE <br />PERMIT"NO. <br />X15 , ti <br />Ll <br />0 <br />3 <br />