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APPLICATION FOR PERMIT <br /> SAN JOAQUIN.LOCAL HEALTH DISTRICT ES <br /> (� <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> !PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ..s:„ <br /> (Complete in.Triplicate) 4 <br /> ti <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 2Q.--gA VCity Lot Size - PM <br /> Owner's Name � � 5 'Addrsss -Z2-� i�`ri � Phone 'a <br /> Contractor License No. Phon <br /> TYPE OF WELL/PUMP; NEW WELL ❑ WELL REPLACEMENT I❑ DESTRUCTIO <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER LJ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES SAL FLD. PROP. LINE i <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS j <br /> INTENDED USE TYPE Of WELL PROBLEM AREA STRUCTION SPECIFICATIONS N Ft <br /> ❑ Industrial ❑ Open Bottom ❑ Mante Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --A x. Depth ❑ Eastern -Surface Seal-Installed by <br /> i -- <br /> Repair Work Done C] e of Pump H.P. M1State Work Done <br /> Well Destruction Well Diameter Sealing Material [top 501 �— I <br /> Depth Filler Material [Below 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 <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 /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number----i <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> i <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 per"mit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m all for all required inspections. Complete drawing on arse side. <br /> Sign d Title: Date: -37 <br /> 1 i <br /> FOR DEPARTMENT USE ONLY {� <br /> Application Accepted by Date ; v Area <br /> Pit or Grout Inspection Date QFinal Inspection by Date <br /> Additional Comments: � ` <br /> ❑ Stk 466-6781 ❑ Lodi 364-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16DI E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE r AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.5/A 5) � �C. a.�r 2— <br /> EH 14-2B V- J �� 1 ` <br />