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APPLICATION FOR PERMIT <br /> ~f 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 /> t 'q, ,3 (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 welltpump and the Rules and Regulations of the San Joaquin <br /> Local Health District.:- is <br /> 7 r 1 <br /> Job Address r s �� City Sfoc k toNLot Size PM <br /> L 2 .S r OR Q <br /> Owner's Name Robert fOI1iSol�' Address �"t 7 Phone <br /> Contractor, <br /> Address License No. Phone <br /> TYPE OF'WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR LIOTHER ❑ <br /> DISTANCE TO T: SEPTIC TANK SEWER LINES DISPOSAL F PROP. LINE <br /> F TION AGRICULTURE WELL WELL PITS/SUMPS <br /> 4 <br /> INTENDED USE TYPE OF WELL OBLEM AREA CO TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack cy Ty Casing Specifications <br /> ❑ Public - ❑ Other # El Delta Depth of Grout Type of Grout <br /> ❑ Irrigation prox. Depth ❑ Eastern Surface Seal Installed by <br /> " State Work Done <br /> Repair Work Done ype of Pump H.P. 1 <br /> Well Destruction `- ElWell Diameteri'.' Sealing Material {top 501 1 <br /> Depth Filler Material (Below 501 l v <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (Noseptic its tem permitted if public sewer is <br /> �hyailabInstallation will serve: Residence Al ,Commercial— Other <br /> Number of living units: Number of bedrooms ' <br /> Character.of.soil to a depth of 3 feet:I-. Water table depth I <br /> SEPTIC TANK Ll Type/Mfg, i" -, ' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ElMethod of Disposal <br /> { Distance to nearest: Well Foundation Property Line JI <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance I nearest: Well Foundation Property Line , <br /> I <br /> s <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS r ❑ Distance to nearest: Well `Foundation' min Property Line i <br /> DISPOSAL PONDS ❑ <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 1egulations 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 /> empioy,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 inspections. Complete drawing on reverse side. <br /> Signed. <br /> Title: Date: <br /> ODEPARTMENT USE ONLY <br /> Application Accepted y <br /> Date. S� Area ©3 <br /> Pit or Grout'Inspection y Date Final Inspection by Date (a <br /> Additional Comments: ' <br /> ❑ Stk 466-6781 b Lodi 3693621 ❑ Manteca 8x3 04 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 - <br /> n <br /> FEEAMOUNT DUE, AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24 1REV.t/e 5} <br /> EK 14-28 v f <br />