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. .. -_ <br /> t <br /> i 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 i <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 /> 4 Owner's Name US-� Address 7 Phone 'e- <br /> antractor S e- Address License No. Phone <br /> TYPE-OF-.WELL/.PUMP,: .—,.,,.ANEW-WELL_C]� _ 11VELL REPLACEMENT ❑_ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM ~REPAIR-❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. 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 Cl Delta Depth of Grout Seal Type of Grout _ <br /> i I Irrigation <br /> --Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done r <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth �. <br /> P Filler Material (Below 50')� �r <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION {Nailable within 200 feet.i f <br /> o septic system permitted if public sewer is <br /> v <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedrooms r <br /> 4 i <br /> Character of soil to a depth of 3 feet: IWater table depth <br /> SEPTIC TANK. r <br /> ❑ Type/Mfg rt Capacity- � No. Compartments <br /> PKG. TREATMENT PLT. O _.. Method of Disposal ry <br /> Distance to nearest: Welt Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size x <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS l I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line k <br /> DISPOSAL PONDS ❑ <br /> 1 hereby certify that 1 have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and j <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, 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 subject to workman's compensa- <br /> tion laws of California." <br /> The applic must call for all required inspections. Complete drawing on reverse side. <br /> r <br /> Signed X Title: .. <br /> - Data: J/ .' <br /> W <br /> FOR DEPARTMENT USE ONLY j <br /> Application Acceptedby Date f <br /> Area <br /> Pit or Grout Inspectio Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> + (REV.tinsl <br /> EH 14-28 <br />