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+. APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> x 1601 E. HAZEL i ON AVE., STOCKTON, CA <br /> Telephone 1209) 466-6781 <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 /> 1f «� <br /> Job Address City Lot Size PM <br /> Owner's Name rllAddress. Phone r <br /> F ; <br /> Contractor dress License NaG / Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHfiWD <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD PROP- LINE <br /> FOUNDATION AGRICULTURE WELL OTHER L PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION IFICATIONS 4 <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Diaof xcavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications <br /> El Public 1-1 Other ❑ Delt Depth of Grout Seal Type of Grout I <br /> ❑ Irrigation _....Approx, Depth Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of P H.P. State Work Done <br /> Well Destruction ❑ Diameter Sealing Material {top 50'1 j <br /> Depth Filler Material (Below 501 <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION'❑ OELMUCTIO iNo septic system permitted if public sewer is ` <br /> F available within 200 feet.) <br /> i <br /> Installation will serve: Residence— Commercial_ Other f <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: j Water table depth <br /> SEPTIC TANK - .Type/Mfg Capacity- Pb No. Compartments <br /> osal <br /> PKG. TREATMENT PLT. Eli " k, Method of Dis p <br /> .Distance to nearest: Well Foundation Property Line <br /> I � <br /> k LEACHING LINE ❑ No. & Length of lines Total length/size <br /> li FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ' DeptFi a Size Number ~ + <br /> SUMPS ❑.. Distance to nearest: Well Foundation 4 Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby; ertify 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 applicant mij%t calL.Nr all require spections. Co e;drawing on r rsW side. <br /> ,. r I $ <br />{ Signed Title; Date: <br /> FOR DEPARTMENT USE ONLY <br /> { \fes <br /> Application Accepted by k Date Area ©� <br /> t Pit or Grout Inspection DateFinal Inspection by Date <br /> i , <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca*-823-7104,—, ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Serviaes'1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 952)1 — <br /> 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY y DATE PERMIT`N0. <br /> INFO CASH Q <br /> + EH13-241REV.1/a E7 <br /> EH 14-28 a <br />