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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �A <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> �{ r <br /> Job Address / �v a City X Lot Size PM <br /> �. Owner's Name Address "`r ^ a46Phone <br /> Contractor 1.zAddress License No Phone <br /> TYPE OF WELLIPUMP: NEW WELL 0 WELL REPLACEMENT 0 DESTRUCTION ❑ <br /> PUMP INSTALLATION 171SYSTEM REPAIR ❑ OTHER 0 <br /> S. . <br /> DISTANCE TO NEAREST: SEPTIC TANK, SEWER LINES r DISPOSAL FLQ. 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 /> I'] Public n Other ❑ Delta Depth of Grout Seal Type of Grout _ <br /> I k Irrigation —.-Approx. Depth I 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work DoneI <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I:) REPAIR/ADDITION l 1 DESTRUCTION VINo septic system permitted if public sewer is Q <br /> 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 r� <br /> PKG. TREATMENT PLT. L1 Method of Disposal <br /> ". Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS• ❑ <br /> 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-Galifornia:"•Contractor's hiring or sub-contracting signature <br /> 1 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 Calif <br /> The applicantum, a1 or all re rr d inspections. Complete drawing on reverse side. �1 <br /> Signed X Title:[�7 Date: <br /> EPARTMENT USE ONLY <br /> 3 <br /> b Application Accepted by Date Z Area 7 <br /> Pit or Grout Inspectio y Date Final Insp�835-6385 <br /> tin by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L i 369-3621 ❑ Manteca 823 7104 © Tracy <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE OUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> EH 14-26 <br /> r.EH 13-241REv.i/ 51 <br />