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., APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT Lth� s <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ` `S� <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 /> r <br /> Jab Address City �O Q nt Siz A10 pM <br /> Owner's Name Address4� Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/P P: NEW WELL ❑ WELL REPLACEMENT ❑ D CTION ❑ <br /> PU INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTI TANK SEWER LINES OSAL FLD. PROP. LINE <br /> FOUNDA N AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WE L PROBLEM AREA CONST TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom Manteca Dia. Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ cy pe of Casing Specifications <br /> F1 Public ❑ Other ❑ Delt Depth of Grout Seal Type of Grout <br /> I I Irrigation —Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H,P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing M ria( (top 501 <br /> Depth Filler Material low 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION I I ESTRUCTION iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other pp. <br /> Number of living units: _--E 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 /> LEACHING LINE ❑ No. & Length of tines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ Number <br /> SUMPS ❑ 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 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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant c;for required�SPOctio- Complete drawing on reverse side. <br /> Signed X Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY ppQ <br /> Application Accepted by Date 3412P� Area ± <br /> Pit or Grout Inspection by Date Final Inspection by;: <br /> - mate 6" 7 <br /> Additional Comments: <br /> A/cr <br /> ❑ Stk 466.6781 ❑ Lodi 3621 ❑ Mante 823-71 ❑ Tracy 835-638 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH <br /> RECEIVED BY DATE PERMIT NO. <br /> y <br /> + EH 1 [Rrs <br /> -24 EV. / 5) � pr�6 <br /> EH 144-26 4`;,/ (,,�(f •(f[J cJ L A� <br />