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APPI_ICATION,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 <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 RulesandRegulations of the San Joaquin <br /> Local Health District. ' <br /> Job Address (-5 S�• City Lot Size PM <br /> Owner's Name Address r Phone ^� g <br /> Contractor ' `�' Address PO /6 .�_ _ License Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION i 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 /> i �(Pomestic/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 /> C <br /> Repair Work Done ❑ Type of Pump.-¢u� H.P. State Work Dane 7� <br /> Weil Destruction ❑ Well Diameter Sealing Material (top 501 <br />[ Depth Filler Material (Below 501 a <br />' TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> " '''available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: Number of bedroom's y I <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg } Capacity No:N,Compartments <br /> PKG. TREATMENT PLT. ❑ *' Method,o-6isposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE 1-1. No. & Length of lines Total length/size t, <br /> FILTER BED ❑ Distance to nearest: Well Foundation ]Property Line - <br /> SEEPAGE PITS ❑ DepthNumber-- <br /> SUMPS ❑ Distance to nearest: Well Foundation-- kProperty 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, 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 f' <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 must call for all required inspections. Complete drawing on reverse side. <br /> Signed X r Title' 1 — — _ Date: ����3 <br /> FOR DEPARTMENT USE ONLY ' <br /> /��� r, <br /> Application Accepted by Y r' Date Area <br /> Pit or Grout Inspection by Date Final Inspection by Date ��d <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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERM17'NO. <br /> L + EH 13-201REV.i/H5) �- [� o-a - - - <br /> EH 14-2S 0.-{ 3 <br />