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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephgne (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 Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> f" w <br /> K Job Address City Lot Size PM <br /> /\Owner's Name rr Address Phone <br /> ' contractor 9 Address License No. Phone <br /> 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 /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> t {`l Public {=1 Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> f I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> ' Well Destruction Ll Well Diameter Sealing Material (top 50') <br /> r <br /> Depth Filler Material (Below 501 <br /> k <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 1.1 REPAIR/ADDITION I I DESTRUCTIO I'(No septic system permitted it public sewer is <br /> k '-available within 200 feet.) <br /> Installation will serve: Residence____ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size nr <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line -` <br /> SEEPAGE PITS I'] Depth Size Number <br /> 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, 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 <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 /> k The applic ust call for all required inspections. Complete drawing on reverse side. <br /> k f/ <br /> Signed /N Title: Date: // 4��_ <br /> I <br /> FW DEPARTMENT USE ONLY ` <br /> t Application Accepted by Date L �^ Area ., <br /> Pit or Grout Inspection by Date Final Inspection by Date �01D <br /> Additional Comments: 1V C7 <br /> 0 Stk 466-6781 ❑ Lodi -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 PERMIT NO. <br /> +.EH 13-21 IREV.k/K 51 rQJ_ +�V1�_W-7 <br />