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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. <br />Job Address &Q.5 Z� <br />City Lot Size ` PM <br />Owner's NameAddress _a!� Phone <br />Contractor's Name �� �/ License No. ? Phone <br />TYPE OF WELL/PUMP: NEW WELL ❑ 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 <br />❑ Domestic/ Private ❑ Gravel Pack ❑ Tracy Type of Casing_ Specifications <br />❑ Public t ❑ Other ❑ DeltaDepth of Grout Seal Type of Grout <br />❑ Irrigation --Approx. Depth ❑ 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 50.1 - + <br />Depth Filler Material (Below 50'1 } - <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br />/ available within 200 feet.) <br />Installation will serve: Residence Commercial Other F <br />< <br />Number of livingr units: —1— Number of bedroo s , <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. ❑ :1 t .1 Method of Disposal <br />Distance to nearest: Well Foundation—,Property Line <br />r i <br />LEACHING LINE X No. & Length of lines !fCO Total length/size .._. o <br />FILTER BED ❑ Distance to nearest: Well,ty Q� ;4- Foundation 0 Property Line <br />SEEPAGE PITS Depth Size Number <br />SUMPS ❑ Distance to nearest: Well 1Sdr 7' Foundation TQ�k Property Line <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 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 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 must call requi inspe ti ns. Complete drawing on reverse side. <br />SignedTitle: <br />Date 3 <br />/FOR DEPARTMENT USE ONLYly A/1,7,* / <br />Application Accepted by L� rr Date o , Area Q <br />Pit or Grout Inspection by Date L D Final Inspection by Date C <br />Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ 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 CK# <br />` INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br />\*EH 13-244REV.10/631 <br />EH 1426 bio <br />U-1 <br />�i <br />