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APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> tComplete 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 City of Size PM <br /> 17 <br /> Owner's Name '—Address one <br /> Contractor Address icense No. +Phone � <br /> TYPE OF WELL/PUMP: NEW WELL ❑ ELL REPL CEMENT / DESTRUCTION ❑ <br /> PUMP INSTALLATION Imo— SYSTEM REPAI [_�]/ OTHER 11DISTANCE TO NEAREST: SEPTIC TANK � SEWER LINES DISPOSAL FLD._ .,.eff- P• LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED US-E TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ In stria) ❑ Open Bottom ❑ Manteca Dia- of Well Excavatibn Dia. of Well Casing <br /> Xomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> l`l Public n Other Ll Delta Depth of Grout Seal Type of Grout — <br /> rigation -Approx. De th i I Eastern Purface Seal Installed y - <br /> Repair Work Done Ll Type of Pump !— H.P. f State Work Done <br /> Well Destruction ❑ Well Diameter .-vim Sealing•Material Itop 50'1 <br /> Depth Finer Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION 1 1 DESTRUCTION l 1 INo 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. E4--—^— — - — "�Metftiad of Disposal - r� <br /> Distance to nearest: Well Foundation — Property Line <br /> 1 <br /> r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Fotindation Property Line <br /> Hy v <br /> SEEPAGE PITS '%I._,Depth Size Numtie�" <br /> SUMPS C Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ 1 <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 Di%trict. <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 6) <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 call far 11 req r ins ctions. Complete drawing o e rse sidN_r1 <br /> % — <br /> Signed X , Title: ' date: f <br /> (FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area <br /> Pit or Grout lnspection by Date Final Inspection-by'--el Date G <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 OLIE. AMOUNT-REMITTED- SASH RECEIVED BY OATE -- PERMIT i'NO. <br /> INFO ` <br /> t.EH 13-241REV.riH55 ���• L70 S �b�Q Q <br /> EH 14-26 <br />