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c <br /> R � — <br /> "` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 12091 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 /> Job Address �_- $ L-a Cit of Size PM <br /> IC�r'1 :5; hon <br /> Owner's Name J Address <br /> r <br /> Contracto Address� License No ��Phon � <br /> TYPE OF WELL/PUMP: NEW WELLe WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATIO SYSTEM REPAIR ❑ OTHER ❑ 1 <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE k <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q; <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS JJ <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 'Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern urface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Wel! Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation wilt-serue;_ Residence_ Commercial Other <br /> Number of living units:_ ` _---Nummber 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 Fouion„ Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total leng e <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> The applicant must aII or a!I re -ed inspections. Complete drawing on reverse side. <br /> Signed X Title:viaz-d Date-- 4y—OZ-7 <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date ` D Area <br /> Pit or Grout Inspection by Date Final Inspection by ate <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/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED 9Y DATE PERMIT'NO. <br /> INFO <br /> s <br /> + EH1 <br /> 3-24 4REV.1/0 5) <br /> EH 14-28 <br />