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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 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 - �'4Gr �� /C 1! City TrCC Lot Size PM <br /> Owner's Name ,( ��( �>Q Address Phone 31 P <br /> i Cont actor Address license No. Phone G'PGrs <br /> i <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 /> FOUNDATIONg - ~AGRICULTURE WELL OTHER WELL � PETS/SUMPS _ <br /> "INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well ExcavationDia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> h ❑ Public Cl Other n Delta Depth of Grout Seal Type of Grout <br /> i <br /> • I i Irrigation �-Approx. Depth l I Eastern Surface Seal installed by <br /> I Repair Work Done ❑ Type of Pump H.P, , _r I State Work Done <br /> + Well Destruction ❑, Well Diameter Sealing Material (top 50') <br /> ,.' Depth Filler Material {Below 50'1 <br /> i - <br /> .. ,E OF SEPTIC WORK: NEW INSTALLATION No f I DESTRUCTION i I o septic system permitted if public sewer is <br /> w available within 200 feet.) } <br /> lnstallation..wili serve­]9esidence, ,Or- -Commercial-.... �ther.�^ _ ,,� ;, -•. <br /> Number of-living units: Number of bedrooms r <br /> r Character of soil to a depth of 3 feet: r - <br /> Water table depth <br /> t DTIC TANK' f Type/Mfg JOIL4r Capacity ,&G No. Compartments <br /> PKG:, REATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well— a� Foundation SCJ Property Line <br /> LEACHING`LINE No. & Length of lines O Total length/size d-- <br /> IT <br /> FILTER BED ❑ SDlstance to nearest: Well—/t'pFoundation SC] Property Line <br /> SEEPAGE PITS I I Depth SizeNumber <br /> SUMPS ;� z: .❑ Distance to nearest: Well `Foundation Property Line <br /> DISPOSAL PONDS ❑ L <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 Ditrict. E <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 subioct to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for all required inspections. Complete drawing on'reverse side. <br /> Signed X - Title: Date: <br /> FOR DEPARTMENT USE ONLY y <br /> Application Accepted by Date U AreAA& <br /> Pit or Grout Inspection by _ Date Final Inspection by Date 6 8� <br /> Additional Comments:: <br /> ❑ Stk 466-678t ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental HealtA Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED 8Y DATE PERMIT'NO. <br /> +.EH 13-24 IREV.I/H 51 <br /> EH 1429 <br />