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APPLICATION FOR PERMIT C—S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 Health District. <br /> Job Address 1.2 �.. PM <br /> City - Lot Size 6 <br /> Owner's Name Address <br /> �''� _ Phone G']� <br /> Coniractot " Address .� <br /> License i"i Phone {� 2 �. <br /> TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES _ _4' DISPOSAL FLD. PROP. LINE r <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 <br /> EJ Domestic/Private CJ Gravel Pack F] Tracy Dia. of Well Casing <br /> Y Type of Casing Specifications <br /> 1-1Public ❑ Other LJ 1 Depth of Grout Seal <br /> L3 Irrigation A Type of Grout <br /> — <br /> Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.p <br /> State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> r•� avajlable within 200 feet.] <br /> Installation will serve: Residence Commercial Qther <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: •� �' Water table depth <br /> SEPTIC TANK LJType/Mfg - <br /> PKG. TREATMENT PLT. EJCapacity No. Compartments <br /> - <br /> 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 /> j f i i <br /> SEEPAGE PITS ❑ Depth Size ! <br /> Number <br /> SUMPS D Distance to nearest: Well' -1�Tr Foundation _ ro P <br /> DISPOSAL PONDS ❑ r Property Line <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. r _ _ _ ___ __' <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 /> The applicant must call for all required ' spections. Complete drawing on reverse sidedAQ - . i <br /> 4� Y r <br /> Signed Title: 1` " <br /> �^ " <br /> Date: <br /> FOR DEPARTMENT USE ONLY t <br /> Application Accepted by --^- `" <br /> Date Area <br /> Q� <br /> Pit or Grout inspection by 0-011, <br /> -Date '° Final Inspection b D. <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 <br /> INFO hJ CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.i <br /> EH 14-2e 35-2 g(� /� �i� ,�] �` /_�/G <br /> v f �/ 6 /VF / f�X <br /> Y <br />