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i <br />` t APPLICATION FOR PERMIT <br /> F SAN JOAQUIN LOCAL HEALTH DISTRICT ZIP,, <br /> 1601 <br /> E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> r (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 5 �' <br /> City Lot Size PM <br /> Owner's Name L �t � Address Phone <br /> ContractorA1 �_ _Address License No.Z�P 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 a Specifications <br /> r7 Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> ll Irrigation ;.y --_Approx'Depth I 1 Eastern f Surface Seal Installed'by _ <br /> Repair Work Dane i' ❑- ,Type of Pump H.P. State Work Done_ <br /> `4 <br /> Well Destruction r ❑� i Well Diameter Sealing Material (top 50') <br /> Depth' Filler Material (Below 50'1 j <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIRTADDITION I I DESTRUCTION I i (No septic system permitted it public sewer is <br /> � available within 200 feet.) I <br /> Installation will serve: 'Residencew'`'dCommercial_ Other - - . ' <br /> Number of living units: Number of bedrooms 1 <br /> r i <br /> Character of soil to a depth of 3 feet:I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg!' Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal � <br /> Distance to nearest: Well i 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— IT—Depth I Size _ Number <br /> SUMPS ❑ Distance to nearest: Well * , FoundationProperty Line <br /> ElDISPOSAL PONDS M +r <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 follow <br /> certi 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 Calif n <br /> The applicant m t 11 r I required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: ` <br /> _ 4 <br /> .- - FOR DEPARTMENT USE ONLY <br /> Application Accepted by � � Date Area 00 <br /> r <br /> i <br /> Pit or Grout inspection by Date—.Final Inspection by Date <br /> Additional Comments:1//7 7 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca a23-7104 ❑ Tracy 5- <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE n <br /> INFO �AAfMOUNT DUE AMOUNT REMITTED ASH RECEIVED BY DATE <br /> " PERMIT'NO. <br /> EH 13-24+ EH 142(5(REV.liK51 V � - 6_/ U ` l -oaJ/ - - <br />- � F <br />