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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON 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 Sart 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. D /� <br /> Job Address t City Lot Size qq 4 PM <br /> Owner's Name _O rl b5-1 Address -, <br /> Phone <br /> Contractorcmif e 1 Address ,0 License No. n Phone r <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 vvv <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 - v <br /> Repair Work Done p, Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth i _ r.. Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION .REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Comm tial` Other <br /> Number of living units: rt Number of bedrooms <br /> Character of of soil to a depth of 3 feet: 77r 71_1� Water table depth <br /> SEPTIC TANK V- Type/Mfg �% Capacity <br /> _ No. Compartments <br /> PKG. TREATMENT PLT. ❑ 3 Method of Disposal <br /> . .� -�r <br /> a f' _ -- Distance to nearest: Well Foundation Property Line _„__ <br /> rr <br /> LEACHING LINE L?”'No. & Length of lines Total length/size, <br /> FILTER BED ❑ Distance to nearest: WellJ !"� Foundation ��_.-_ Property Line__ _ <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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."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 California." <br /> The applicant must tail for all required inspections. Complete drawing on reverse side. <br /> Signed X_._ ��_ Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Q_ .-. Date V � �� _ Area <br /> Pit or Grout Inspection by Date Final Inspection by k.T C;1_ Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 923-7104 Tracy 835-M <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 Ilf. Piazelton Ave., P.O. Box 2009, Stk., CA 955201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 1324(REV.1 i H sl <br /> EH 14-28 o Q0 <br />