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APPLICATION FOR PERMIT <br /> " SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZELTON 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 "S, ��,, r City Lot Size PM <br /> Owner's Name F a Address Phone <br /> Contractor� i �� ��Address 35 Q CA MINa License No. '-L(D ;- 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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> f'1 Public i1 Other F1 Delta Depth of Grout Seal I Type of Grout _ <br /> i I Irrigation --Approx. Depth l I 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 t <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1:1 REPAIR/ADDITION l 1 DESTRUCTION o septic system permitted if public sewer is <br /> j available within 200 feet.) <br /> Installation will serve: Residence_ Comrhercial—_­—OtheF--- "--`-- ' <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: j Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> s <br /> r Distance to nearest: Well Foundation Property.Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weil Foundation i Property Line <br /> SEEPAGE PITS C I Depth Size._ ._ Number <br /> SUMPS Ll 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 /> s 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 /> tioo law Californi f <br /> he app(ica t ca for reT. 's ions. o e drawing onre fgrse side. <br /> Signed itle: Date: J <br /> FOR DEPARTMENT USE ONLY <br /> a _Area. <br /> _Application AcceptDate o_ad by _ A _ _ _. .. _ - J - <br /> PP <br /> Pit or Grout Inspection by Data Final Inspection by Dat ` <br /> Additional Comments: <br /> I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental H ealth.Permit/Services.1601-E. Hazelton Ave., P..O._Box.2009, Slk.,_CA 95201_ <br /> I <br /> FEE <br /> )NFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.riy 5i <br /> EH 14-26 f <br />