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S <br /> APPLICATION FOR PERMIT <br /> SAN JOAQU"IN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE 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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. cc ,� <br /> Job Address City J Lot Size ;7 qtt_`"'� PM <br /> Owner's Name Address �� _ Phone` <br /> `.r7 <br /> Contractor f ddress`_ r / License No: " Phone <br /> TYPE OF WELL/PUMP: NEW W LL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing 1 <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 7 <br /> * Public F1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation --Approx. Depth 1 I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material f e w 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITION ADESTRUCTION INo septic system permitted if public sewer is <br /> V1__' available within 200 feet.) n <br /> Installation will serve: Residence_ Commercial_ Other J <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: q 4 Water table depth (' <br /> SEPTIC TANK ❑ Type/Mfg ; Capacity 0 No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal. <br /> Distance to nearest: Well �Foundation Property Line <br /> 4 <br /> LEACHING LINE ❑ No. & Leng&,?f lines ' ^ Total length/size <br /> FILTER BED ❑ Distance to nearest: ndati operty.Line <br /> - <br /> SEEPAGE PITS I I Depth -Size Number <br /> � j <br /> SUMPS 11Distance to nearest: W t ±nclal,on Pro �y Line t �t <br /> DISPOSAL PONDS ❑ OI <br /> I hereby certify that I have prepared this application and that th work will be done in accords ce 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 of subcontracting 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 ust call for a required inspections. Complete drawing on reverse side. 11' <br /> Signed X Title: Date: �9 T_b 111— <br /> Tit <br /> DEPARTMENT USE ONLY <br /> Application Accepted by �'rt�C�+r"L►h�� r _ _ Date Area <br /> ! y <br /> Pit or Grout Inspection b ti Date Final Inspection by <br /> Additional Comments: ' M �1—y 3 D Dmf ] Yn tAl�� <br /> ❑ Stk 4&6-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Pefmit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO MOUNT DUE AMOUNT REMITTED CCK 9 RECEIVED BY DATE PERMIT'ND. <br /> +.EH 13-24(REV.t i H 5) M 0 <br /> EH 14-26 c l/i.l� VVV <br />