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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NO��J�/t � <br /> 1601 E. HAZELiON AVE.,.STOCKTON, CA C <br /> t "'Telephone (209) 466-6781 <br /> PERMIT EXPIRES'l YEAR FROM DATE ISSUED ..•. — 4 �`�L �� <br /> I (Complete:in Triplicate) 11;+ .'Ipr�-, <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 /> x r City. ` Lot Size ^ PM <br /> Job Address � � n .. . - <br /> Owner's Name Address d Phone <br /> Contract Address License No. Phone <br /> ' TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> rs 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 /> i <br /> i ❑ industrial F1 Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ DomestiO Private ❑ Gravel Pack ❑ Tracy Type of,Casing Specifications <br /> ❑ Public ❑ Other ❑ Delia Depth of Grout Seal Type of Grout <br /> r <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> I Repair Work Done Type of Pump H.P. State Work Done <br /> e <br /> well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> r <br /> Depth I Filler Material IBelow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION [No septic system permitted if public sewer is <br /> available within 200 feet-1 <br /> � <br /> Installation will serve: Residence Commercial_ Other ^ <br /> I Number of living units:, " Number of bedrooms <br /> r Character of soil to a depth of 3 feet: I -�'"'""f" Water table depth <br /> SEPTIC TANK CIType/Mfg' '1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ C <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> t LEACHING LINE ❑' No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i SEEPAGE PITS ❑ Depth { Size T Number <br /> k SUMPS ❑. Distance to nearest: Well Foundation Property Line <br /> 1 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 /> that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify <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 subject to workman's compense <br /> tion laws of California." <br /> The applicant ust call for all required i specti ns Co plat drawing on rV ide. J _ <br /> Signed X Title: Date: ~— <br /> - .� <br /> f OR DEPARTMENT USE ONLY <br /> Application Accepted by °�^�`^'� Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: , <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621- ❑ Manteca 823-7104 ❑ Tracy 835-6385 ' <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009;Stk:, CA 95201 <br /> FEEAMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. <br /> INFO , rf ! <br /> k a-EH 13-241REY.,/K51 2�- --.c?f. F r.� '� 2i. <br /> EH 14-26 <br />