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APPLICATION FOR PERMIT <br />I � v <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 _7/� ��'� ��� -City _� �/� :ra Lot Size PM _ <br />r <br />Owner's Name ✓- <br />Address Phone 7"?Z Z Z <br />Contractor's Name p = '� " 5 License No. .2 Sri — Phone <br />TYPE OF WELL/PUMP: NEW WELL El WELL REPLACEMENT ❑ DESTRUCTION C j <br />PUMP INSTALLATION ❑ SYSTEM REPAIR ❑"OTHER C1 j <br />DISTANCE TO'NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO.PROP LINE <br />FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br />INTENDED USE <br />❑ Industrial <br />❑ Domestic/ Private <br />❑ Public <br />❑ irrigation i <br />Repair Work Done ❑ <br />Well Destruction ❑ <br />TYPE OF WELL <br />❑ Open Bottom <br />❑ Gravel Pack <br />❑ Other <br />---Approx. Depth <br />Type of Pump <br />Well Diameter — <br />Depth <br />PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />❑ Manteca Dia. of Well. Excavation <br />❑ Tracy Type of Casing <br />❑ Delta Depth of Grout Seal <br />❑ Eastern Surface Seal Installed by <br />H:P. State Work Done _ <br />Sealing Material (top 501 <br />Filler Material (Below 501 <br />TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION(No septi system <br />rmiittei <br />Installation will serve: Residence— Commercial Other i <br />Number of living units: Number of bedrooms e <br />'--.--}— -_ Water table depth <br />Character of,soil,to-a-depth of -3 feet: <br />SEPTIC TANK El Type/ Mfg µ - _ Capacity No. Compartments <br />Method'•of Disposal . <br />PKG. TREATMENT PLT. ❑ .�L s <br />-Distanc'e' to -nearest L -- - Well ° Foundation -Property Line <br />Dia. of Well Casing <br />Specifications <br />'Type of Grout.— <br />I <br />it public sewer is <br />3 <br />f7 <br />LEACHING LINE ❑ No. & Length of linesTotal length/size <br />FILTER BED ❑ Distance to nearest: Well " Foundation Property Line <br />SEEPAGE PITS © Depth QV Size Number <br />SUMPS ❑ Distance to nearest: { _Well Foundation Property Linea € <br />DISPOSAL PONDS ❑ <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." Contractors 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." <br />The applicant t call for all required inspectiong. Complete drawing on reverse e. <br />Signed ' _ r � Dat % O <br />FOR DEPARTMENT USE ONLY <br />Application Accepted by <br />CN Date Area <br />Pit or. Grout Inspection by _ Date Final Inspection by. Date <br />Additional Comments: <br />❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br />Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br />r EH 13-24 SREV. 1016 <br />EH 14-26 ` <br />FEE <br />AMOUNT DUE <br />AMOUNT REMITTEDCASH <br />RECEIVED BY DATE PERMITAO. <br />INFO <br />) <br />a oma./ <br />