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R <br /> APPLICATION FOR PERMIT �S <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 I <br /> PERMIT EXPIRES 1 YEAR 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 /> Ir <br /> City of Size PM <br /> Job Address <br /> Aldd essF <br /> Owner's Name_ t —� <br /> Address License No. <br /> Contractor Phone <br /> WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> TYPE OF WELLQUMP: NEW WELL ❑ OTHER ❑ <br /> MP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLD. PROP. LINE _— r <br /> FOUNDATION GRICULTURE WELL PITS/SUMPS �� <br /> INTENDED USE TYPE OF WELL PROBLEM AR RUCTION SPECIFICATIONS `! <br /> ❑ Industrial ❑ Open Bottom anteca Dia. of Well n <br /> Dia. of Well Casing <br /> Specifications <br /> ❑ Domestic/Private ❑ ack ❑ Tracy Type of Casing of Grout — <br /> fl Public ❑ Other n Delta Depth of Grout Seal <br /> I 1 Irrigation —..Approx. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Dane <br /> Weil Destruction [-] Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> F TYPE OF SEPTIC WORK: NEW INSTALLATION I] REPAIR/ADDITIOc system pe <br /> N l I DESTRUCTION availabetlwi within 200 feet.)mI if public sewer is <br /> Installation will serve: Residence— Commercial Other <br /> kNumber of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a depth of 3 feet: <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 Cl Distance to nearest: Well Foundation Property Line <br /> Number <br /> SEEPAGE PITS l I Depth Size <br /> i <br /> CSUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> i DISPOSAL PONDS ❑ f <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 shah not <br /> employ any person in such manner as to stoma subject to workman's compensation laws of California." Contractor's hiring or sub contracting signature <br /> certifies the fallowing: "I certify that i 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 applica t us c II f I r re n . Complete drawing on reverse side.- <br /> (/V{ <br /> Signed r Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by _ <br /> Date. Area <br /> Pit or Grout Inspec iorC. Date Final Inspection by Date <br /> Additional Comments: <br /> ' ❑ Stk 466-6781 ❑ Lo6i 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> i 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 RECEIVED By DATE PERMIVNO.O+ EH 13-241REV.i/K51 `EH 14-26 1 <br />