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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 4w. <br /> 1601 E. HAZELTON AVE., STOCKTON, CA l <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED r_ <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 k <br /> Local Health District. —JO <br /> a + ` Qct City Calm Lot Size PM <br /> Job Address <br /> tCQr'`�a' <br /> Owner's Name <br /> V �' ka t! Address r E, �$�{ Y Phone ' <br /> ContractoraC Address License No.t7 +P Phone <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT)❑ DESTRUCTION ❑ d•"' r ; <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHERX <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 l <br /> ❑ Industrial Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> �F Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> 7U Irrigation —..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done W Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [.l REPAIR-./ADDITION E 1 ' DESTRUCTION l I (No septic system permitted it public sewer is <br /> available within 200 feet.) ]` <br /> Installation will serve: Residence_ Commercial— Other C <br /> CZ). <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. ❑ Method of Disposal ') <br /> Distance to nearest:. Well Foundation Property Line <br /> i LEACHING LINE ❑ No. & Length of lines Total lengthlsize <br /> I FILTER BED ❑ Distance to nearest: Well Foundation) Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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, and <br /> rules and regulations of the San Jo in Local Health District. e <br /> fi Home owner or licensed agent's sign t e Mies 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 e a ss b'ect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following: "I certify t t in rfor ace f the work for which this permit is issue , I shall employ persons subject to work an <br /> lion <br /> c mpensa- <br /> tion laws of California." <br /> The applicant r qui i ions Com late drawing on reverse si <br /> Signed X <br /> Title: Date: <br /> I <br /> OR DEPARTMEN U E ONLY <br /> Application Accepted by Date l�`� – l Area 13 <br /> iate Final Inspection by �� C Date <br /> I Pit or Grout Inspection by <br /> 1 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., GA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> r INFO <br /> I + EH 13-24 IREV. <br /> EH 10-28 <br /> ;} <br /> i <br />