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x f <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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. <br /> Job Address 364 So if. City 4Rd Lot Size PM <br /> Owner's Name �" f' (4ddress Phone C <br /> Contractor Address l License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. 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 Ll Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ("1 Public n Other F1 Delta Depth of Grout Seal Type of Grout . <br /> I I Irrigation —.Approx. Depth I I Eastern Surface Seal Installed by A <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ �� <br /> Well Destruction ❑ Well Diameter Sealing Material atop 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK( NEW INSTALLATION I 1 -REPAIR/ADDITION ( 1 DESTRUCTIO lNo 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 UNE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 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 Di§trict. <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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applica ust call f II required inspecti ns. late drawing on reverse sid <br /> Signed X [�– Title:G✓�J;R at � ���Date: 16 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by _ Rata 4 — Area <br /> Pit or Grout Inspection iby,,- t, Date Final Inspection Date <br /> 1L <br /> Additional Comments:w�"��"" <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -71 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Silk., CA 95201FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> CASH RECEIVEQ BY OATS ;PERMIT NO. <br /> EH 13-24(REV.EH 14-28 <br />