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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone {209} 466-6781 <br /> PERMIT EXPIRES '{'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 vC•City Lot Size PM <br /> Owner's Name ' 11 u <br /> Z" tic--Nt 1 Address ��/3a 2 A2e-rN( ] Af Ke .Phone G <br /> Contractor Address License No. Phone <br /> f <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 0 Open Bottom ❑ Manteca.,-;,, � .Dia. of-Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public i ❑ Other ( ❑ Delta Depth of Grout Seat Type of Grout <br /> I Irrigation --Approx. Depth 11-Eastern Surface Seal Installed by <br /> Repair Work Done <C Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter F Sealing Material (top 501 <br /> Depth ' , = Filler Material (Below 5011 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 0 REPAIR/ADDITION I I DESTRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence f Commercial— Other V <br /> Number of living units: Number of bedrooms <br /> t <br /> ,� Character of soil to a depth of 3 feet: Water table depth - <br /> SEPTIC TANK EJ"Type/Mfg, Capacity' No. Compartments- <br /> PKG TREATMENT PLT. ❑ Method of Disposal <br /> " Distance to'nearest: Well <br /> Foundation'""^"+"" Property Line <br /> . yy <br /> S E t <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ­0Distance to nearest. Well Foundation Property Line }} <br /> i <br /> SEEPAGE PITS 1 1 Depth Size _ Number e <br /> SUMPS L'I Distance to nearest: Well Foundation 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, r ` <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 compenure <br /> tion laws of California." <br /> The applicant must call for all required pections. Complete drawing on reverse side. 1 <br /> rn� -U_. - <br /> ' �Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: y l7f a ; ! <br /> ❑ Stk 466-6781 ❑ Lodi 369-36 1 ❑ Manteca 623-7104 EVT7racy 5-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave„ P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT N0. <br /> +'.EH13-241REV.riA5) "64 / _� /{ <br />