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Y y"' APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t ., <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED i <br /> (Complete in Triplicate) <br /> fComp <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 k <br /> Local Health District. <br /> City of Site PM <br /> Job Address . I <br /> Address Phone <br /> Owner's Name <br /> Contractor Address <br /> License No. �S Phone � p� <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 0 <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 /> G ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing a Specifications \h <br /> E MPublic FI <br /> Other (7Delta Depth of Grout Seal Type of Grout <br /> I I irrigation Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE-40F SEPTIC WORK: -NEW INSTALLATION I] REPAIR/ADDITION-[-)-DESTRUCTION (No s septic <br /> system <br /> hit 200 fef tied if public sewer is' <br /> + .. <br /> k 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 <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line A_ <br /> SEEPAGE PITS VI Depth Size Number <br /> kSUMPS L-i 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'cbunty ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> l rtify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I ce <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 /> F certifies the following. "I certify that in the performance of the work far which this permit is issued,l shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st II or Ire ed inspections. Complete drawing on reverse side.. ` <br /> Signed X Title: <br /> Date: — 1� T g Y <br /> i <br /> f FO EPARTNIENT USE ONLY <br /> Date Area <br /> Application Accepted by � 5 Z <br /> Pit or Grout Inspection by Date Final Inspection by Da e <br /> h - <br /> Additional Comments: iyy <br /> ❑ Stk 466-6781 ❑ Lodi 369-3611 ❑ Manteca B23-7104 ❑ 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 /> k <br /> FEEOUNT RUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT NO. <br /> INFO ` <br /> +.EHt3-244REV.t/n51 <br /> EH 14-ZB . j <br />