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APPLICATION FOR PERMIT <br /> .� SAN.JOAaU1N LOCAL HEALTH DISTRICT PEG lVD <br /> ` 1601 F. HAZEL I ON AVE., STOCKTON, CA R <br /> r Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR'FROM DATE ISSUED �plT <br /> ,:a t (Complete in Triplicate) }Nv1R��M�N R�CES <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein descry d. This application is <br /> € made H compliance with San Joaquin County Ordinance No, 549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> Local Health District: H'� <br /> Job Address <br /> t, C1ty Lot Size i PITA <br /> Owner's Name r. Address r �. ` <br /> ' Phone <br /> CContractor, _Address azo: <br /> TYPE OF WELL/PUMP: NEW WELL ❑ "`"`� License No. � Phone �_ 1. � <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> l DfSTANCE TO NEAREST: SEPTIC TANK OTHER <br /> SEWER LINES DISPOSAL FLD. PROL <br /> FOUNDATION AGRICULTURE WELL <br />' OTHER WELL PiTS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca — Dia. of Well Excavation <br /> Domestic/Private ❑ Gravel Pack ' Dia. of <br /> ❑ Tracy Type of Casing <br /> ❑ Public El Other El Delta Specifick <br /> Depth of Grout Seal Type of <br /> ❑ irrigation ---Approx. Depth ❑ Eastern <br /> C Repair Work Done T Surface Seal installed by <br /> Type of Pump _ H.P. State Work Done <br /> IF 0 <br /> Well Destruction ❑- Well Diameter Sealing Material (top 50'1 <br /> DepthFiller Ma <br /> _ aterial (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑�REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> installation,will serve: Residence Commercial— Other r available,within 200 feet.) <br /> --••+ <br /> Number of living units: Number of bedrooms r{ i <br /> Character of soil to a depth of 3 feet: <br /> p � <br /> Water table depth <br /> SEPTIC TANK <br /> ❑ Type/Mfg J41-11 `t Capacity <br /> PKG. TREATMENT PLT. F-1 ^--- 1 No. Compartments <br /> t ,� Method of Disposal <br /> Distance to nearest: (Nell R5- �SFoundation_ <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER SED Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS ----------- Number <br /> .❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS Property Line <br /> ------------------ <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, ander <br /> rules and regulations of the San Joaquin Local Health District. t .,E <br /> Home owner or licensed agent's signature certifies the following: <br /> employ any�person in such manner as to become subject to Workman's certify mpensation laws ormance of California."Contractor's <br /> work for lch this hiring or sub Ill <br /> act nglshE <br /> signllltnot <br /> certifies the following,"I certify that in the perforrlSance aF the work far which this permit is issued, f shall employ persons subject to workman's g signbompLure <br /> tion taws of California." ' _. <br /> nsa- <br /> The applicant must call for all required inspections. Complete drawing on ave ide. u + f <br /> : a <br /> Signed X— Title: ( .�YrL�L <br /> Date: <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by i <br /> Date pC Area d <br /> Pit or Grout Inspection by—A <br /> Date <br /> Final lnspection !Jy Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 LJ 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 /> R <br /> FEE AMOUNT DUE CK <br /> INFO , AMOUNT REMITTED H RECEIVE&BYHDA TEPERMIT"NU <br /> EH 1426 <br />