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APPLICATION FOR PERMIT 7 <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ; <br /> II Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> f 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 /> o <br /> Job Address �% / / Y1 Y �r� /J City —Sr7 Lot Size PM <br /> � q <br /> Owner's Name � hJ©r'� y Address ��/ 7` J „'/� r/'�/1� Phone <br /> Contractor_ Address ✓ License No. Phone 7G <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT.❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> CE TO NEAREST: SEPTIC TANK SEWER LINES _DISPOSAL FLD. PROP. LINE <br /> ATION AGRICU T-URE=WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL - AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> ❑ Industrial ❑ Open tt6fr' ❑ Manteca Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ravel Pack ❑ Tracy Type of Casing Specifications — <br /> i"1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I Irri <br /> Approx. Depth <br /> —»-I-I-Eastern- --�---ti-Surface•Seab-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 (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION No septic system permitted if public sewer is <br /> a ilable 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. ❑ 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 l Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> t <br /> DISPOSAL PONDS O <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 /> i 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."Contractor's hiring or sub-contracting signature <br /> i 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 must call for all req ired inspections. 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 Ins tion b Date Final Inspection by Date <br /> f <br /> Additional Comments: .3 l <br /> ❑ Stk 466-6781 O 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 <br /> INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> +.EH1 -241REV.iiNs1 � �� ^�a <br /> EH t4-Ze <br />