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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone 1209? 466-6781 �v <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED _, o)A <br /> t.jjFti� i . <br /> (Complete in Triplicate) C '� ;,y,•,,t l Scy2v1LES <br /> p�1zM <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 Y "� �h� � - City Lot Size PM <br /> � 0 <br /> Owner's Name Address <br /> Contractorg Address License No Z Phone <br /> TYPE OF WELL/RUMP: 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 Ll Gravel Pack © Tracy Type of Casing Specifications <br /> t`l Public Cl Other F Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation _..Approx. Depth I I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of.Pump H.P. l�]l State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material itop 50') <br /> Depth Filler Material {Below 50'I - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l I REPAIR/ADDITION i I DESTRUCTION i 1 (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 /> 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 I Depth Size _ Number <br /> SUMPS 11 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 taws 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 parsons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must <br /> call for all required inspections. Complete drawing on averse side. <br /> Signed XTitle:. <br /> FOR EPARTME USE ONLY �f <br /> Application Accepted by �. --- Date / Area <br /> Pit or Grout Inspection by Date Final Inspection by Date 1" <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 623-7104 L1 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +.EH 13-24 IREV.r/H 51 , J � <br /> EH 11-28 <br />