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s <br /> 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. Y <br /> Job Address 4 7; zQ { + _ _ City 7- yl Lot Size PM <br /> Owner's Name +C�^�� _ � � - -- Address «1 Phone <br /> Contractor �ress ULA: -n.. License No.Zf4�4.1 Phan, <br /> TYPE OF WELLIPUMP: ! NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: IC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUND AGRICULTURE WELL OTHER WELL S/SUMPS <br /> l <br /> INTENDED USE TYPE OF WELL EM AREA CONSTRUCTION SP TIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of xcavation Dia. of Well Casing ` <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy ype ing Specifications -V(,,• <br /> ❑ Public ❑ Other ❑ D Depth of Grout Type of Grout �jl <br /> ❑ Irrigation --Approx. Dept Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pu H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth "'Filler Material IBelow 501 <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 j <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 /> Di}stance to nearest: Well Foundation Property Line I <br /> 7 ' <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ -Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth # Size JNumber'- <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ +: 1 <br /> I hereby certifythat 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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." i <br /> The applicant. u call for all required inspeLions Complete drawing on revoo side.. 4f <br /> Signed 1� - Title: Date: <br /> F_O_R DEPARTMENT USE ONLY <br /> Application Accepted by Date /y" Area <br /> Pit or Grout Inspection by Date T r Final Inspection by Date <br /> c <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 CYTracy 635-631 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED C SH <br /> RECEIVED BY DATE PERMIT''NO. <br /> INFO <br /> 02 <br /> + EH 13-24(REV.)/a 51 <br /> EH 14-28 <br /> { I <br />