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4 - <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> IComplete in Triplicate) <br /> ade to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This applic <br /> Application is hereby malion is <br /> compliance with San Joaquin County Ordinance Na 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> made <br /> Local Health District. <br /> Job Address <br /> I �� City Lot Size PM <br /> ��" � <br /> Owner's Name <br /> Address <br /> Phone <br /> Contractor <br /> �� Address License No.� Phone <br /> TYPE OF WELL/PUMP: N WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR Ll OTHER C] \� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ industrial tions ' <br /> f , Type of Casing Specifica <br /> ❑ Domestic/Private ❑ Gravel Pack LI Type of Grout <br /> Depth of Grout Seal <br /> {"1_Puhlrc n 0 <br /> ther Delta P <br /> I I Irrigation , _ .-Approx. Depth i I Eastern __ Surface Seai Installed by _ <br /> H.P.. State'Work Done <br /> Repair Work Done ❑_ Type-of.Pump_- _ _ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 50') <br /> fff+ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION {:I REPAIR/ADDITION [ I DESTRUCTION evaiiabPelwithin 200 teetit�ed i( p�ubficwer is <br />[ r rl ,r- <br /> Installation will serve: r Residence Coinmerciai__ Other <br /> Number of living uniW Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <br /> p <br /> SEPTIC TANK 11 --Type/Mfg—•.--"� "-� "' <br /> Caacity No. Compartments <br /> -� t <br /> PKG. TREATMENT PLT.•❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line y <br /> LEACHING LINE ElNo. & Length of lines Total length/size <br /> k FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS t I Depth Size Number <br /> E SUMPS Ll 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 /> 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, 1 shall not <br /> i 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 compensa- <br /> tion laws of Califorrr . <br /> The applicant Is <br /> ca or all required ons. Complete drawing on reverse side. <br /> Signed <br /> Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> E <br /> Application Accepted by Date <br /> Date Final Inspection by' <br /> Pit or Grout,Inspection by <br /> f Date <br /> Additional Comments: �i�Q ' � * <br /> LJStk 465-6781 ❑ L i 369-3 ❑ Manteca -7104 ❑ Tracy 835-638 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Bax 5tk., CP 5201 <br /> FEEC RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> AMOUNT DUE AMOUNT REMITTED HHS <br /> ♦.EH 1324(REV.t/N 5.) <br /> EH 14-26 <br />