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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 /> tt 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 /> I .. <br /> Job Address ��� ��City Lot Size PM <br /> ��1 I ���Address A <br /> Owner's Name �f,Jr7J?�. Phone'20 <br /> f _ <br /> f Contractor Jr ?,*"Address y 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 /> E 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 "cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy _, Type of Casing Specifications <br /> O Public 0 Other ❑ Delta Depth,of Grout Seal Type of Grout <br /> kkk ❑ Irfi <br /> g ation ---Approx. Depth ❑ Eastern s Surface Seal installed.by <br /> Repair Work.Dofie ❑ Type of Pump - H.P. State Work Done <br /> 1 <br /> Well`lJestruction Cl Well Diameter Sealing,Material {top 501 , <br /> .. Depth Filler Material(Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION , REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> �a Installation will serve: Residence__Le_ Commercial_ 'Other. C <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 pacify No. Compartments <br /> f►_..: PKG. TREATMENT PLT.El Method of D' o <br /> Distance to nearest: Well . a Foundation ' �' Property Line <br /> 4 <br /> k LEACHING LINE No. & length of lines <br /> '!qf42'--� ° Total length/size � <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS Depth C Size Number <br /> r SUMPS ❑ Distance to nearest: Well Foundation^ �Property Line + <br /> DISPOSAL PONDS ❑ s <br /> fI 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 /> Fill 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, 1 shall not <br /> employ any person in such manner as to become subject:ib 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." k <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> F1Signed X TitleDate: <br /> : FOR DEPA MENT USE ONLY , <br /> Application s <br /> pp Accepted by .Date. Area <br /> Pit Grout Inspection by ate _ Final Inspection by Date <br /> Additional Comments:` <br /> ❑ Stk 466-6781 ❑ Lodi 359-3621 : ❑ Manteca' 823-7104 ❑Tracy 635-6385 <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 RECEIVED BY DATE t PERMIT`NO. <br /> INFO I CASH <br /> .. 1..._. .. — . - .' .. <br /> EH <br /> -. �]? <br /> EH 1428 IREV.1/8 51 0• j. c]�7 V�+ /v;''S <br />