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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 Health District. f <br /> l 'Job Addrly <br /> ess /J VO C ��.�f,�} p ap e� <br /> i City Lot Size PM <br /> I ° ` Phone <br /> 1 �(� Owner's Name 6 (� � e , Address �� ��� /Y c p dD^ —' <br /> I Contractor CIL-t , Address icense No.2 9 0913 0 Phone <br /> TYPE OF WELL/PUMP: ^ _ NEW WELL.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> j 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 /> r INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma6,teca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> r] Public Ll Other - ❑ Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation — <br /> J —.-Approx. Depth " f I Eastarn Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pum i' <br /> p YP P t. 'H•P. - State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 56 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION,[I REPAIR/ADDITION I I DESTRUCTIOINo septic system permitted if public sewer is <br /> 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 P <br /> SEPTIC TANK ❑ Type/Mfg <br /> Capacity - No. Compartments - <br /> PKG. TREATMENT PLT. ❑ P <br /> Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED <br /> ❑Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth I—Siie ` Number <br /> SUMPS ❑ Distance to nearest: We`ll Foundation Property Line <br /> DISPOSAL PONDS ❑ r <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 tonworkrrlan'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 /> t drawing <br /> The applicant must call for all required inspectionsdrawin <br /> Co <br /> . mplete g on reverse side. � <br /> k9 <br /> \ Si ned,1L, Title: - *- / Date: <br /> I <br /> FOR DEPARTMENT USE ONLY p <br /> p Y <br /> 'i� r I �$ <br /> Application Accepted b � / <br /> Date Area / j <br /> i <br /> Pit or Grout Inspection by Date Final Inspection by <br /> /� i Date <br /> Additional Comments: _ ? _,Q I <br /> ❑ Stk 466-6781 ❑ Lodi 369 3621 ❑ Manteca 823-7104 O Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 'i <br /> FEE AMOUNT DUE AMOUNT REMITTED <br /> INFO RECEI�ByiPERMIT•No+ EH.13-24►REV.t i x 5)EH 14-26A.� clt— t <br />