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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 /> 1. <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 Ryles and Regulations of the San Joaquin <br /> Local Health District <br /> ' 1 ,,} <br /> Job Address 7 /� �� W city ^JIA/C "' Lot Size . ' PM <br /> Owner's Name G k? U -- Address - _ - — Phone <br /> Contractor_ - Address / icense No- Phone <br /> 1WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> �----__eUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD._, PROP. LINE <br /> FOUNDATION TURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CON TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom _1 Manteca Dia. of Well Exca Dia. of Well Casing <br /> ❑ DomesticlPmate El Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation —Approx. Depth ID Eastern Surface Seal Installed by <br /> + Repair Work Done ❑ Type of Pump WP. t State Work Dane <br /> Well Destruction ❑ Well Diameter _ Sealing.Material(top 501 <br /> Depth Filler'Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ iDESTRUCTION (No septic system permitted if public sewer is 1 <br /> available within 200 feet.) `! I <br /> Installation will serve: Residence_ Commercial— Other l <br /> Number of living units: Number of bedrooms <br /> i 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 n_ <br /> Distance to nearest: Well _ Foundation Property Line J� <br /> LEACHING LINE ❑ No. &Length of lines __ Total length/size - <br /> FILTER BED !_1 Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS L Depth Size Number _— <br /> SUMPS ❑ Distance to nearest: Well Foundation _ Property Line <br /> DISPOSAL PONDS Cl <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."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 equine ins tions. Complete drawing on reverseside. <br /> Signed XW244 . Title: Data: <br /> - FOR DEPART ENT USE ONLY <br /> Application Accepted by Date <br /> Pit or Grout Inspection by _ Date_ Final Inspection by Date <br /> Additional Comments: _ - <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823.7104 F1 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 H RECEIVED BY DATE PERMiT'NO. <br /> INFO <br /> a EH 13-24(REV.1/85) 1 - O <br /> I EH 14-26 1 <br />