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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 /> y <br /> PERMIT.EXPIRES 1 YEAR FROM DATE ISSUED I <br /> (Complete tin.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 /> Job Address V, Fj,e— 0ty5�o Lot Size k. � PM <br /> Owner's Name r�t � � �Address Phone <br /> I T2'-V 6 Wa/y�e/ �UG/ r I✓vre� <br /> Contractor Address 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 FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ----Approx. Depth © 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 18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> E available within 200 feet.) <br /> Installation will serve: Residence_ Commercial____ 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. O Method of Disposal <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 Property Line <br /> SEEPAGE PITS `❑ %Depth Size Number <br /> SUMPSti IJDistance to nearest: Well Foundation Property Line <br /> le­ 1 -1-11 <br /> DISPOSAL'PONDS [J 'f <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. 5 <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 /> a <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. �^ <br /> Signed X //�/ Tiil 2�: .. Date: Z C <br /> k <br /> �FOR� MENT USE ONLY Application Accepted by `-' Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date , f3 <br /> fkdditional Comments: <br /> Stk 466-6781 ❑ Lodi 369461 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> (/`e'p�licant- 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 CA RECEIVED BY DATE PERMIT'NO. <br /> y INFO <br /> + EH-13-24(REV. <br /> ' EH 1428 ' <br />