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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br />{ 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 <br /> + .# PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> (Complete in Triplicate) f <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 /> Job Address Ci Lot Size PM <br /> Owner's Na ddress Phone <br /> Contractor Address Ch � �Q Li cense [fa. Phor <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 <br /> FOUNDATION AGRICULTURE WELL WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA C CTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Mante Dia_ of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack racy Type of Casing Specifications <br /> (`1 Public i=1 Other Cl Delta Depth of Grout Seal Type of Grout <br /> -- <br /> I I Irrigation pprox. Depth i I Eastern Surface Seal Installed by _ <br /> Repair Work Done Type of Pump H.P, State Work Done_ (n <br /> Well Destr ' n ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I ] REPAIR/ADDiTION I I DESTRUCTIO (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: Number of bedrooms } <br /> Character of soil to a depth of 3 feet: Water table depth <br /> fl <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. 0 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 l Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ t <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 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 /> The applica ust call for all required inspections. Complete drawing on r rse side <br /> Signe Title: �> Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by L, ,Date Area <br /> Pit or Grout Inspection by Date Final Inspection by DateGa��y ' <br /> A dilional Comments: <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Mant ca 523-7104 0 Tracy 835-6385 \� <br /> plicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 �I " <br /> FEE AMOUNT DUE AMOUNT REMITTED CK H RECEIVED BY DATE PERMIT NO. <br /> INFO rr s` <br /> ` + EH 13-24 1REV.+/n 51 41 1l <br /> EH 74.2e ,] ll LLD 1 [ ` <br />