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APPLICATION FOR PERMIT �J <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT _ <br /> 1601 E. HAZELTON AVE., STOCKTON, CA Qt;T .. 1984 <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED SAN-JOAQUIN LOCAL <br /> (Complete in Triplicate) HEALTH DISTRIC-' <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 Lot Size <br /> PM `N <br /> I Owner's Name Address Phone <br /> Contractor's Name License No. Phone 1 ac <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> r — PUMP INSTALLATION ❑ SYSTEM REPAIR [ OTHER E2DISTANCE 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 /> %omestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S <br /> ❑ Public Specifications <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done "A Type of Pump H,p. State Work Done CL ifily, r-[� <br /> Well Destruction ❑ Well 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 /> t <br /> i Installation will serve: Residence— Commercial— Other available within 200 feet.) <br /> r Number of living units: Number of bedrooms �x <br /> I Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK E2Type/Mfg Capacity No. Compartments <br /> j. PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> .,_SEEPAGE.PITS ❑ Depth Size Number <br /> SUMPS El 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 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 for all required ins ctions. C plate drawing on reverse side. l <br /> /� I <br /> Signed If/ Title: <br /> Date: <br /> FOR DEPARTMENT USE ONLY L <br /> Application Accepted by Date/.-P <br /> ©/ I <br /> Area J <br /> Pit or Grout Inspection by Date Final Inspection byi r <br /> Date) <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi. 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8354M5 <br /> Applicant-- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 f <br /> i. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK <br /> x i INFO CASH RECEIVED BY DATE PERMIT'NO, <br /> + EH 13-24(REV.10/83) <br /> EH 14-26 ��,( g <br />