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APPLICATION�FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE.;.STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED:. + r <br /> ., , - (Complete in Triplicate) ,r <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 i <br /> Local Health District. ' <br /> t5-Q mot Size r• PM <br /> Job Address - City <br /> Owner's Name Address Phone g <br /> Contractor G✓ Address License N Phone �a <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> J PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> r 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 />` <br /> Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications }� <br /> � <br /> D'Public Ll Other ❑ Delta Depth of Grout Seal C" C°" Type of Grout. <br /> ❑ Irrigation --Approx. Depth ❑ Eadien Surface Seal Installed.b= —� <br /> Repair Work Done Type of P_um_p _Q_�,,� - H:P.:_ _ State Work Don <br /> _ �.l . <br /> _- <br /> Well Destruction�❑-===Weil-Diameter. Sealing Material atop 501 <br /> Depth Filler Material lBelow 501 - <br /> TYPE OF SEPTIC WORK: -NEW-INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> { Number of living units: Nurnber of bedrooms M <br /> Character of soil to a depth of 3 feet: "� Water table depth <br /> SEPTIC TANK ❑ Type/Mfg-4- l P- Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ { Method of Disposal <br /> Distance to Barest: 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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to,nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ !IN <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 I <br /> rules and regulations of the San Joaquin Local Health District. - } <br /> f Home owner or licensed agent's signature'dertifies the following: "I certify that in the performance of the work for which this permit is issued, l shall not <br /> k 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 /> r certifies the following: "I certify that in the tierformance of the work for which this permit is issued. I shall employ persons subject to workman's compensa- <br /> tion laws of California." + I <br /> The applicantcall for all requ' ins"' <br /> ction omplete drawing on -verse side.. <br /> Signed X S Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> _.,,_ l ��• "�j r I <br /> Application Accepted by E Date Area <br /> Pit or Grout Inspec n b Date Final Inspection by Data <br /> i Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <br /> �. Applicant- Return all copies to: Environmental Health Permit/Services 1601•E`Hazelton Ave., P.O. Box 2009, Stk:, CA 95201 <br /> l FEE AMOUNT DUE AMOUNT,-REMITTED .'; .CASH' RECEIVED BY DATE PERMIT'NO. <br /> INFO �y p 1f�j <br /> r '+ EH 13-241pEV-tins5 QO [ 14/1 .. - ��r(.,10 - <br /> EH 14.28 1 l <br />