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APPLICATION FOR PERMIT <br /> pViQl �.! <br /> SAN JOAQUIN LOCAL HEALTH'�DISTRICT <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED ENVIROME'��AL HEALTH <br /> (Complete in Triplicate) . FERICT/5ER ICES <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 welUpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. i <br /> ' f <br /> City Lot Size PM <br /> Job Address <br /> ress Phone <br /> Owner's Name C / <br /> Contractor <br /> Address 4Q� <br /> FiceZnseNo. G S'/3 Phone ( <br /> WELL REPLACEMENT ❑ DESTRUCTION <br /> NEW WELL ❑ 171TYPE OF WELL/PUMP:. OTHER ❑ <br /> II PUMP INSTALLATION ❑ SYSTEM REPAIR I� <br /> DISTANCE TO NEAREST: SEPTIC TANK '" SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> 4, <br /> V FOUNDATION_. AGRICULTURE WELL..,. OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> i Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> - Type of Casing Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack •❑ Tracy 9 <br /> ❑ Other Cl Delta Depth of Grout Seal Type of Grout <br /> R! Pilblic (�n <br /> i 11 Irrigation _..Approx. Depth l l Eastern Suri Seal Installed by v l <br /> Repair Work Done ❑ - Type of Pump ^ ' H'P.— ►-� State Work Done d <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material IBa)ow 501 <br /> iTYPE OF SEPTIC WORK: NEW INSTALLATION 1 1 REPAIR/ADDITION I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) �^ <br /> Installation will serve: Residence— Commercial Other l f } <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> _ <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 <br /> SEEPAGE.PITS I 1 Depth Size Number <br /> r SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> -DISPOSAL PONDS ❑ <br /> 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 /> t " <br /> The applicant must callAr all required inspections. Complete drawing on reverse side. <br /> Signed X-7r ST <br /> Title: _ ��� - Date: — <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by 1VVDate r Area <br /> Pit or Grout Inspection by <br /> Data Final Inspection by Date Q �� <br /> Additional Comments: <br /> ❑.Stk 466-6781 ❑ Lodi 369-3621 ` . ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> iApplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.D. Box.2009, Stk., 095201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> ♦ EH 13-24 1REY.1/n 51 �5, � 9-4 � �'al <br /> EW 14-26 e <br />