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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209).466-6781 <br /> I� PERMIT EXPIRES 1 YEAR FROM DATE?ISSUED •, <br /> .,(Complete in Triplicate) u: <br /> k Application is hereby made to the San Joaquin Local Health District for permit to construct and/or install the work hereiri described:This application is <br /> I made in compliance with San Joaquin County Ordinance No:.549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> f' Local Health District. <br /> PM <br /> I e Cit Lot Size <br /> i Job Address <br />` IYNAddress Phone <br /> Owner's Name _ <br /> Address � ,License No. Phon <br /> I Contract r <br /> TYPE OF WELL/PUMP: NEW WELL F1 WELL REPLACEMENT ❑ DESTRUGTI L3PUMP INSTALLATION El ; SYSTEM REPAIR C2OTHEERR ❑ I <br /> DISTANCE TO NEAREST: SEPTIC TANK <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I __ Dia. of Well Casing <br /> ❑ Ini-- ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> � Specifications <br /> a ❑ Domesu�Pfivz.:e ❑ Gravel Pack ❑ Tracy Type of Casing Yp <br /> T e of Grout <br /> Ll Public ❑ Other ❑ Delta Depth of Grout Seal <br /> 9 ❑ Irrigation ---,-Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H P State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ,top 50'1 �- <br /> Depth Filler ri (Below 50") <br /> F SEPTIC WORK: NEW INSTALLATION ❑ REPAIR DOITIO DESTRUGTION �_JNo septic_system_permitted ilpublic sewer is <br /> TYPE O .. 'Alm available within 200 feet.) ! <br /> r y <br /> Installation will serve: Residence Commercial, Other <br /> Number of living units: Number of b rooms _ <br /> Character of soil to a depth of 3 feet: �---""'Water-table-depth-- <br /> Capacity_ No. Compartments 'L. <br /> SEPTICTANK ElType/Mfg + i <br /> Method of Disposal ; <br /> PKG. TREATMENT PLT. ❑ <br /> roperty Line <br /> Distance to nearest: Well Foundation P <br /> V u � � <br /> LEACHING LINE "'iT No- & Lingthtof line's,;7�( Total lengthlsize ' f <br /> r <br /> y?Property Line.. <br /> FILTER BED iLD Distance to nearest: �IIVe�" Foundation <br /> +L . <br /> 3 / - 1 <br /> .J <br /> SEEPAGE PITS €i►S,_DeptIn Size � - Number <br /> _ <br /> SUMPS <br /> nearest: Well _ Foundations Property Line <br /> Q Distance to _ — <br /> `K �, <br /> DISPOSAL PONDS ❑ - �- <br /> i nd that the work will be done iccordance'with San Joaqui i county ordinance <br /> n as, state laws, and <br /> I hereby certify that 1 have prepared this application ae <br /> f 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-forwhich xhis 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 /> I The applicant must call for all r ired i pections. Complete drawing on reverse sr <br /> Title: � Date: <br /> Signed X i <br /> FOR DEPAR ENT USO LY <br /> Date Area <br /> l Application Accepted by <br /> Date' <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: - <br /> ❑ 5tk 466-67$1 d Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> h Permit/Services 1601 E. Hazelton Ave., P.O..Box 2009, Stk., CA 95201 <br /> Applicant - Return all copies to: Environmental Healt <br /> FEE CK C RECEIVEQ BY' DATE PERi1AIT'NO. <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH <br /> ` + EH t3-24 SREv.I H sf �� ` Cid - <br /> Yt7r$i� b3�-- <br /> EH 14-26 ! - - - <br />