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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT i <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <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 welllpump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> City <br /> Lot Size PM <br /> Job Address <br /> Phone <br /> Address 4 <br /> Owner's Name b <br /> L� Phone <br /> f� License No. <br /> Contractor's Name DESTRUCTION ❑ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> PUMP INSTALLATION ❑ <br /> SYSTEM REPAIR C3 OTHER El <br /> ° SEWER LINES � DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK OTHER WELL PITSISUMPS <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE TYPE OF WELL 1y PROBLEM AREA CONSTRUCTION SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom '❑ Manteca pia. of Well Excavation Specifications <br /> k ❑ Tracy Type of Casing <br /> i <br /> ED Domestic/Private E] Gravel Pack Depth�df Grout Seal Type of Grout <br /> ❑ Public <br /> C1 Other <br /> 11 Delta <br /> ---Approx. Depth ❑ Eastern ''Surface Seal Installed by 1 <br /> ❑ Irrigation I�,; State Work Done (� <br /> Repair Work Done ❑ Type of Pump Sealing <br /> 5ealirig Material (top 501 <br /> Well Destruction ❑ Well Diameter Filler Material {Below 50) <br /> Depth—I <br /> --�— ,_ — — <br /> TYPE OF SEPTIC WORK: NEW INSTAii'LLAT ON ❑'REPAIR/ADDITION _DESTRUCTION ❑ aNailabpelwit in 200 feet.) i# public Bawer is <br /> Installation will serve: Residence Commercial— Other <br /> 90 <br /> Number of living units: Number of bedrooms Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg Method of Disposal <br /> PKG.. TREATMENT PLT. ❑ Property Line <br /> Distance to nearest: Well Foundation <br /> ° y�- <br /> Total length/size <br /> 'LEACHING,LINE� No. & Length of lines r S <br /> - ❑ Distance to nearest: Well � �— Foundation�Q� Property Line�— <br /> FILTER BED <br /> A 1. e -Size Number <br /> Depth � <br /> SEEPAGE PITS � P t Line <br /> Distance <br /> ` <br /> I SUMPS ElDistance to nearest: Well 1926� Foundation /l) Property <br /> :. .� y; <br /> f DISPOSAL PONDS ❑ 4 <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 /> 1 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 issue I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant st call f l req 'e ins ions. Complete drawing on reverse side. <br /> /verse , <br /> Title: !"�? ' " Date: <br /> r Signed <br /> FOR DEP MENT USE ONLY <br /> pate Area_— <br /> Application Accepted by m <br /> C ( <br /> Date Final Inspection by <br /> Date <br /> Pit or Grout Inspection by <br /> � <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-63% <br /> Applicant Return ail copies to: Environmental Health <br /> Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA.- 01 <br /> I FEE CK RECEIVED BY DATE PERMIT`NO. <br /> AMOUNT DUE AMOUNT REMITTED ,CASH <br /> INFO. <br /> + EH <br /> � <br /> 1}24(REV.10!631 •_ C7 a <br />