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w <br /> • y: <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTr <br /> 1601 E. HAZEL—PON 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 City Lot Size 670�QLVP PM <br /> Owner's Nam r Phone �Z& <br /> � <br /> Contractor A Address License No. Phone <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER ❑ <br /> DISTANCE TO ILEA ST: SEPTIC TANK SEWER LINES DISPOSAL FLD. ROP. LINE <br /> TION AGRICULTURE WELL 0 h{€R'W LL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL EM AREA C TION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Monte ia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private, ❑ Gravel Pack racy Type o Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation pprox. 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 (top 501 <br /> Depth Filler Material (Below.50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIONavailable within 200 feet./(No septic system permitted if public sewer is <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 LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: - -_Well_ -Foundation Property Eine <br /> DISPOSAL PONDS El <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 call for all requir i spections. Complete drawing on Xqverse side. <br /> el <br /> Signed' �if/Il�. _ Title: Date: ���� <br /> FOR EPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout inspection by Data <br /> Final Inec <br /> sption b Date r .? � <br /> Additional Comments: <br /> O Stk 466-6781 ❑ -3621 ❑ Manteca -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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> + EH 13-24(REV.1/65)1 <br /> E � � �S t 3` 1 <br /> li 428 <br />