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rI 3 G d� <br /> 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 A <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 City Lot Size PM <br /> Owner's Name Address one �✓ r � <br /> Contractor's Name L ease No. / eJ IS1/phone <br /> r. 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 /> a <br /> IN NDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ndustrial ❑ Open Bottom ❑ ManManteca 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 /> i ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done t;�Type of Pump b141 Tj H.P. I_C_ State Work Done <br /> I Well Destruction ❑ 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 /> I `Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms f <br /> Character of soil to a depth of 3 feet: __._Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> t PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well 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 ❑ Depth Size Number <br /> SUMPS ❑ 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 /> Nome owner o ' d agent's signature certifies the following:-1-certify that in the performance of the work for which this permit is issued, I shall not <br /> 1 employ any _son in s ch manner as to.become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies foilowing: '1 certify that in th"e rforma of the work for which this•permit is issued.I shall employ persons subject to workman's compensa- <br /> tion Zppli <br /> of Californ' ." <br /> The teafor- all�qu' i ._.Complete dr ' o1'i erse si <br /> Sign ,,Title: Date: <br /> /_ ! FOR DEPARTMENT USE ONLY } <br /> Application Accepted by �✓ Date Area <br /> Pit or Grout Inspection by Date Final I pection by ate <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi.-369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all co�40: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 <br /> � f <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CK <br /> RECEIVED BY DATE PERMIT'N0. <br /> '+ EH 1321(REV.101831 �S <br /> EH 1426 s• r'. � <br />