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APPLICATION FOR PERMIT <br /> 1` SAN JOAQUIN LOCAL HEALTH DISTRICT r <br /> kl 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> " \ f 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 /> I 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 /> C <br /> Job Address _C�25- <br /> QP DT City Lot Size PM <br /> Owner's Name Address vr � <br /> Phone <br /> Contrac r Addret C�b <br /> TYPE OF WELL/PUMP: �icens � Ph e <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER El <br /> LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU <br /> ❑ UW <br /> Industrial ❑ Open Bottom El Manteca CIFICATIONS <br /> ❑ Domestic/Private ❑ Gravel Pack a. of Well Excavation Dia. of Well Casing N <br /> ❑ Type of Casing <br /> M Public f_-1 Other ❑ Delta Specifications �t <br /> Depth of Grout Seal Type of Grout <br /> I I Irrigation ox. Depth I 1 Eastern <br /> Surface Seal Installed by 11 <br /> Repair Work Done ype of Pump H P <br /> Well Destruc " State Work Done _ <br /> ❑ Well Diameter Sealing Material (top 501Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t I DESTRUCTIO (No septic system permitted if public sewer is <br /> Installation will serve: Residence_ vailable within 200 feet.) <br /> Commercial_ Other_ _ <br /> Number of living units:: Number of bedrooms Q <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK ❑ Type/Mfg Water table depth <br /> PKG. TREATMENT PLT. ❑ Capacity No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED ❑ Distance to nearest: Well Total length/size <br /> Foundation Property Line <br /> SEEPAGE PITS 11 Depth <br /> Size <br /> SUMPS Ll Distance to nearest: Well Number <br /> DISPOSAL PONDS El Property Property Line <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: "1 certify that in the performance of the work for which this permit is issued,I shall employ <br /> tion laws of aliforfollowing: <br /> " <br /> • P Y Persons subject to workman's compensa- <br /> tion <br /> applic t must call for all required in ctions. Complete drawing on re se <br /> Si <br /> Title:— w o s C (f <br /> Date: �_l � <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by � <br /> Date Area <br /> Pit or Grout Inspection <br /> Date Final Inspection by <br /> Additional Comments: r� / Date 4� 02 <br /> ❑ Stk 466-6781 ❑ Lodi 3621 ❑ Manteca 823-7104 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E.❑Hazel on Tracy A3 e.,P50. Box 2009, Stk., CA 95201 <br /> tt � <br /> FEE AMOUNT DUE t <br /> INFO AMOUNT REMITTED CK RECEIVED BY <br /> CAS DATE PERMIT NO. <br /> +.EH 13-24(REV.i i H 5) .� <br /> EH 14-26 <br /> �_z7. 9 <br />