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APPLICATION FOR PERMIT <br /> SAN JOAO,UIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.; STOCKTON, CA '4 <br /> Telephone (209) 466-6781,, <br /> PERMIT EXPIRES IiYEAR"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.:a:.,rr si <br /> Job Address City Lot ize PM_ <br /> Owner's Names— Address Phone <br /> Contractor —" �*_ - Address--' License No, Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ �-.WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTAL14TION ❑ „SYSTEM REPAIR ❑ 0 ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK -SEWER LINES / DISPO PROP. LINE <br /> FOUNDATION ICULTURE WELL HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA UCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom ❑ Manteca -Dia. Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ .,Type of Specifications <br /> } ❑ Public ❑ Other Delta Depth of Grout 1 Type of Grout <br /> Ll Irrigation =�4ppr epth ❑ Eastern . Surface Seal Installed by 3 <br /> Repair Work Done ❑ Typ Pump H.P. �*- t State.Work Done N <br /> Well Destruction ❑ elf Diameter i Sealing Material (top 501 <br /> Depth• ' Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ - REPAIR/ADDITION ❑ DESTRUCTIONA(No septic system permitted if public sewer is <br /> G j 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 feel: Water table depth <br /> �•r SEPTIC TANK ❑ :Type/Mfg ; Ca No. Compartments <br /> PKG. TREATMENT PLT. ❑ ,: } Method of Disposal <br /> Distance to rnearest: ell Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of Total length/size <br /> FILTER BED ❑ Distance earest: Well Foundation Property Line <br /> 1 SEEPAGE PITS ❑ epth 1 Size Number <br /> SUMPS ❑ .,'Distance to nearest `"'Well "`y Foundation n � 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 /> k 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 /> IE 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 /> The applicant must call for all_requi inspections. Complete drawing on reverse side.Title: <br /> Signed Z7 <br /> Date: <br /> FOR DEPARTMENT USE-ONLY " <br /> .,.-Z F <br /> Application Accepted by ` Date 2 S77A Area- v <br /> Pit or Grout Inspection'by Dated Final Inspection by <br /> Additional Comments:v; <br /> ❑ Stk 466-6781 ❑ Lodi 369 1 Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazehon Ave., P.O. Box 2009, Stk.,_CA.95201 . <br /> FEE CK <br /> INFO AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT-NO. <br /> + EH 1324(REV. <br /> EH 14-28 <br />