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r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 4 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 G City Lot Size M <br /> Owner's Name dres _. ��` —f Phone <br /> Contractor ress &��fAeerse No. 3 Phone <br /> TYPE OF WELL-/PUMP. .NEW W LL ❑ WELL REPLACEMENT ❑ _ DESTIRUCtION In <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 i ❑ Gravel Pack Cl Tracy Type of Casing Specifications <br /> F] Public n Other ❑ 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. State Work Done_ el, ° <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50'1 <br /> Depth Filler Material (Belo t <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I') REPAIR/ADDITION 6f DESTRUCTION I ] INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial ZOlher h <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. ❑ / Q Method of Disposal <br /> Distance to nearest: Well Foundation r ® Property Line <br /> LEACHING LINE ❑ No. & Length of lines` _ Total length/.size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> _ 1 <br /> SEEPAGE PIT i I Depth 1f Size Number <br /> S 5 ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <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 applicant must call forrequir inspections. Gomplete drawing o ev rse side. <br /> Signed X Title: *byA�,�_ <br /> ate: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by LL DArea <br /> Pit or Grout Inspection by Date `v nal Inspection Date <br /> Additional Comments: <br /> ;Fpr%- <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7110tf ❑ Tracy 835-6385 <br /> Applicant - Return all c6pi6s to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK CASH RECEIVED BY DATE PERMIT'NO. <br /> a EH 13-21(REV.tiK5) �! <br /> EH 14-26 !/ <br /> Z S L-f 4 <br />