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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE.T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES i 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. I <br /> t <br /> Jobt Address - ` - City t,Size <br /> •yam <br /> Owner's Name Address y A -efzke!7 Yl �i' Phone <br /> 4 <br /> Contractoir's Name. - No. Phone <br /> TYPE OF WELL/PUMP: U NEW WELL ❑ WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ (SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONr AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEMAREA, CONSTRUCTION SPECIFICATIONS # <br /> ❑ Industrial ❑ Open Bottom ElManteca i.Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Packl ❑ Tracy Type of Casing Specifications <br /> ❑ Public I] 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. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 501 <br /> I <br /> Depth I Filler Material IBelow 50') ` <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION D DESTRUCTION ❑ No septic system permitted if public sewer is <br /> available within 200 feet.) ` s� <br /> Installation will serve: Residence_ki Commercial_ Other <br /> Number of living units: Number of b9pooms vle <br /> Character of soil to a depth of 3 feet: i - .r Water table depth <br /> SEPTIC TANK ❑ Type/Mfg .CapacityNo. Compartments <br /> PKG. TREATMENT PLT. ❑ Cs` Method of Disposal <br /> Distance to nearest: Well 1 Foundation (�' Property Line O <br /> �' ` _ <br /> LEACHING LINE ❑ No. & Length of lines � Total length/size- <br /> FILTER <br /> � g <br /> FILTER BED ❑ Distance to'nearest: Well rO 4- Foundation{ Property Line <br /> SEEPAGE PITS D Depth Size Number <br /> SUMPS ,� Distance to nearest: Well r Foundation Property Line <br /> DISPOSAL PONDS �0 LOO IJ"' '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.';iContractor'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." r <br /> The applicant m st qal4or. I requir inspections. Comple drawing on reverse side. <br />'i Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r Date G ea <br /> Pit or Grout Inspection by Date Final Inspection by D <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 63x6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> CK 0 <br /> FEE <br /> l <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT"NO. <br /> + EH 13-24(REV.10/831 <br /> EH 14-28 <br />