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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> r Telephone (209) 466-6781 PCO <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 /> r Local Health District. <br /> Job Address <br /> j City � � Lot Size PM <br /> Owner's Name a ,-O dress F' Phone <br /> �p� r <br /> Contractor Address License No. Phone <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. PROP. LINE <br /> 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 /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public F Other ❑ Delta Depth of Grout Seal Type of Grout--- <br /> I <br /> rout _I I irrigation —.Approx. Depth I ] Eastern Surface Seal Installed by <br /> r Repair Work Done U Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter 5ealirly Material (top 50') <br /> Depth Filler Material IBelow 50'1 {� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION L I DESTRUCTION No septic system permitted if public sewer is 47 <br /> 1 ` � 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 /> SEPTIC TANK ❑ Type/Mfg Ca acit <br /> �,,,,.. <br /> "� Capacity— No. Compartments ' <br /> .,,,,.�PKG. TREATMENT PLT. CI , <br /> 111 Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No.-8 Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property line <br /> SEEPAGE PITS I i Depth Size Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <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: "1 certify that in t rformance of the work for which this permit is issued, I shall employ <br /> tion laws of California." p Y persons subject to workman's compensa- <br /> tion . <br /> The applic mu If f requir d i p.ctions. Complete drawing on reverse side. <br /> Signed X Title. Date: �d <br /> - �F ��LISE ONLY - <br /> Application Accepted by M— Date 640 Area <br /> Pit or Grout Inspection by Date` Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi �69-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> I� <br /> FEE .MOUNT DUE jAOUNT RET CK RECEIVED BY DATE <br /> PERMIT'NO. <br /> { CASH O..^ <br /> ..EH 14-241REV.tiN57 rZ /dEli 10.28 V( ((f'l <br />