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APPLICATION FOR PERMIT <br /> i 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 -� 5� - � City Lot Size PM 6 <br /> Owner's Name r +� Address SL1� [-y I lt�� 1�= 'C- Phone - <br /> J�,�r n ` <br /> Contractor k rg`�'"�dress,-cx)c> NZ�•)'..tri+vY� License N Phone <br /> FPE OF WELL/PUMP:' N,EW 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 /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal - Type of Grout <br /> ❑ Irrigation ---Approx.'Depth ❑ Eastern Surface Seal Installed'by! <br /> Repair Work Done ❑ Type of Pump H.P. t State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material [top 501 ' <br /> Depth +' I "" -Filler Mateirial (Below' 501--4-1- <br /> TYPE <br /> O'1'µ 1TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Mo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve Residence_i Commercial_ Other <br /> + IJ <br /> Number of living units: Number of bedrooms ► <br /> Character of soil to a depth of 3 feet} Water table depth <br /> SEPTIC TANK XType40 Capacity .No. Compartments <br /> PKG. TREATMENT PLT'❑ ' IyMethod of Disposal <br /> e 1 <br /> 1: }Distance to nearest: Well Foundation II Property Line <br /> j. <br /> LEACHING LINE © No. Length oClines Total:length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation t Property Lirie <br /> SEEPAGE PITS 1,❑, Depth, } Size Number p <br /> SUMPS t ❑ Distance to nearest: Well Foundation 1 Property Line <br /> DISPOSAL PONDS I ❑ ; <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 ryWealth Disi:ff T' <br /> Home owner or licensed agent's signature cert-dies 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."Contractors 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 mus all for all required inspections.-Complete dra Ing o -r id } <br /> Signed <br /> FOR-DEPART-HENT USE'ONLY <br /> Application Accepted by __— Date �'1 � Area <br /> Pit or Grout Inspection by D to Final Inspection by Date Sf <br /> i <br /> Additional Comments: <br /> ❑ Stk 466-6781 O Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 83540B5 <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/a 5135- <br /> EH 14-28 " L <br />