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r � <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> l <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> F. (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. 1662 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address ! _ City Lot Size PM <br /> i <br /> Owner's Name T_„ � oy 4C1 dress Phone <br /> tS�9a Z` Phone LS � <br /> Contractor's Name License No. <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION'PIC SYSTEM REPAIR ❑ OTHER ❑ <br /> "DISTANCE TO NEAREST: SEPTIC:TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑. Industrial 12 Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well.Casing <br /> j�mestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout VE <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by v IE <br /> Repair Work Done ❑ Type of Pump H.P. �i State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50'1 �p <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 /> a <br /> available within 200 feet.) <br /> i 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. ❑ j Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I _ <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth F ` Size Number ^ <br /> SUMPS ❑ ,Distance tolriearest:.,,.,,Well4, _Foundation - Property Line - <br /> DISPOSAL PONDS ❑ <br /> 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."Contractors 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 mu§g cAll for all require4 inspections. Complete drawing on reverse side. <br /> Signed Title: Date: _ <br /> ZF R DEPARTMENT USE ONLY <br /> + <br /> i Application Accepted by /J'�y Date. �a Area <br /> Pit or Grout Inspection by Date Fina! Inspection by Date <br /> Additional Comments: — f <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 83556385 F <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 CK RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> + EH 13-24(REV.10183? <br /> EH 14-26 <br />