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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL-J ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> t <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 /> E 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 /> I <br /> f' R <br /> 7.1 <br /> Job Address c �" �s(W City Lot Size f Z �., PM <br /> Owner's Name [' e k S�e_ Address Phone <br /> Contractor's Name s C � ,�c� License No. ���7d� I <br /> Phone 1 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ED <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ v� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump -H.P. -- - -T- - State Work Done q 1 <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') <br /> Depth Filler Material (Below 50) <br /> .�J <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic""system permitted if public sewer is a } <br /> Y - - --available within.-200.feet.). �•-' <br /> Installation will serve: Residenc4l_,**� Commercial_ Other ' <br /> Number of living units: Number s <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ElType/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> `Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE tS No. & Length of lines �91ength/size oFILTER BED ❑ Distance to nearest: WeII Foundation t Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS Distance to nearest: Well Foundation-92-0-L-1 Property Cine c2O <br /> DISPOSAL PONDS ❑ 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 permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Cali ia." �'; <br /> The applica t cal r ire inspections. Complete drawing on reverse'side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY xAL " <br /> f. <br /> Application Accepted by ` Da;e' K Area / <br /> Pit or Grout Inspection by `Date Final-inspection by" Date <br /> Additional Comments: ,._-. .._ _-_« -r :• __ __ _ <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 j <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 CK# <br /> INFO CASH RECEIVED 6Y DATE PERMIT'N0. r <br /> ff <br /> + EH 13-24(REV.10183) <br /> EH 1428 <br />