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APPLICATION,FOR PERMIT Ti'✓ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA Afuj �' <br /> Telephone (209) 466-6781 t <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) -w <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'{ i "l <br /> Job Address �/V � _ City �rrN/ Lot Size_ PM <br /> Owner's Name <br /> ` Address /� _ Phone /5 <br /> Contractor t Address License No. Phone <br /> TYPE OF WELLlP P: NEW WELL 1`7WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 1-1SYSTEM REPAIR ❑ OTHER O� <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHEITWELL PITS/SUMPS <br /> INTENDED USE' r TYPE OF WELL PROBLEM AREA CONST •CTION SPECIFICATIONS <br /> ED Ind .ustrial ❑ Open Bottom ❑ Manteca -Di of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing-!-- Specifications <br /> ❑ Public ❑ Other eta )rk �Dept4�of-Grout Seal Type of Grout <br /> ❑ Irrigation ---4pprox. De ❑ Eastern Surface SealInstalledby <br /> Repair Work Done ❑ Type of P p H.P. # State Work Done Well Destruction ❑ iameter Sealing Material (top 501 <br /> Depth Filler Material (Below-50') . <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo'septic system permitted if public sewer is <br /> . available within 200 feet.) <br /> Installation will serve: Residence— Commercial— Other - N t <br /> Number of living units: Number of bedrooms a <br /> l Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments m <br /> i <br /> PKG. TREATMENT PL- E]-- �� µ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> r <br /> LEACHING LINE ❑ No. &Length of lines y Total length/size <br /> FILTER BED ❑` Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ .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."Contractor's 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 required inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �iArea 0� <br /> Pit or Grout Inspection b Date Final <br /> Inspection by Date <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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> ah <br /> + EH 13-24 IREV.1/95) <br /> EH 1428 <br />