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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT DOr-e <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> T Telephone (209) 466-67$1 <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 4 <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 f 1 y :2V/-'3!0"37 <br /> / City G Lot Size PM <br /> Owner's Name SA[ a. ddress �a �— ,`IrZ <br /> -3-9 �- M a-- J Phone <br /> Contractor 0 Address 6cet"`r <br /> W License No. / Phone f <br /> TYPE OF WELL/PUMP: NEW WELL 'WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISPOSAL FLD, PROP, LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ industrial ❑ Open BottomManteca Dia. of Well Excavation <br /> Domestic/Private � �Gravel Pack Dia. of Well Casing <br /> , <br /> ❑ Tracy Type of Casing ogur <br /> ❑ Public � ❑ Other Specifications /W <br /> ❑ Delta Depth of Grout Seal Type of Grout P <br /> ❑ Irrigationr <br /> ��Appr ox. Depth ❑ Eastern Surface Sea! Installed by <br /> Repair Work Done ❑ t Type of Pump :_ H p <br /> State Work Qoine <br /> Well Destruction ❑ , Well Diameter -Sealing Material atop 501 <br /> i DepthFiller M (Below <br /> aterial 50'] <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence_e Commercial! Other available within 200 feet.) <br /> Number of living units: Number of;bedrooms 4,F <br /> Character of soil to a depth of 3 feet:SEPTIC TANK 1 ❑ Type/Mfg Water table depth <br /> Ca acitPKG. TREATMENT PLT. C3P Y No¢Compartments <br /> L Method of Dispo( <br /> Distance to-nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. &Length of lines Total length/size <br /> FILTER BED ❑ Distance to"nearest: Well Foundation <br /> Prope4Line <br /> SEEPAGE PITS c ❑ Depth SizeNumber ' <br /> SUMPS f ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> DISPOSAL PONDS ❑ /d <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 of California." Contractors 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 mus II f all requiEgd ns ctions - plate drawing on reverse side. <br /> Signed ��- Title: Date: <br /> y FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 0 13 <br /> r Area <br /> Pit or Grout Inspection by ate nal inspection by <br /> ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK# <br /> INFO CASH RECEIVED BY DATE PERMITNO. <br /> + EH 13-24 iREV.1/65) <br /> EH 14-25 D bV P <br />