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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r r. 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> `C Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> I Local Health District. <br /> i JobAddress dC EOG= Cit <br /> Y Lot Size PM <br /> Owner's Name _ Address Phone' <br /> Contractorw f <br /> Address ense No, 6�Zz�phone <br /> TYPE OF WELL/PUMP: NEVV WELL WELL REPLACEMENT DESTRUCTION ❑ <br /> PUMP INSTALLATION <br /> SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK, �Q�! SEWER LINES - ^,ISPOSAL-FLD_ P..,ROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL QO' PITS/SUMP <br /> I <br /> f INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> II ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> /Domestic/Private ?!)(Gravel Pack ❑ Tracy Type of Casing ✓G Specifications / <br /> 1 Public (� Or er r ❑ Delta Depth of Grout Seal r Type ype of Grout.._�e���_ <br /> 1 I Irrigation r�Zr+--Approx, Depth IIastern Surface Seal Installed by <br /> Repair Work Dane ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material )top 50") <br /> I Depth Filler Material !Below 50'1 ) <br /> A r TYPE OF SEPTIC WORK: NEW INSTALLATION 1-1 REPAIR/ADDITION I ) DESTRUCTION I 1 (No 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 - I,. "No. Compartments <br /> r <br /> PKG. TREATMENT PLT. El :4 Method of Disposal <br /> I Distance to nearest: Well Foundation I w Property Line <br /> LEACHING LINE ❑ No. & Length of fines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> 1 . <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well FoundationProperty Line { <br /> DISPOSAL PONDS El <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 shalt not <br /> employ any person in such manner as to become subiect to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> i 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 re ired inspections. Co plete drawing on reverse side. <br /> Signed X Title: _ date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date 2p ( <br /> Area <br /> Pit or Grout Inspection by Date Final Inspection by <br /> .- <br /> Additional Comments: _ <br /> ❑ Stk 466-6781 ' ❑ Lodi 369-3621 0 Manteca 8234104 ❑ Tracy y835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> 4 }. <br /> FEE AMOUNT DUE AMOUNT <br /> + - AMOUNTREMITTED INFO CASH <br /> 3H RE+CEIVI.V.ED BY DATE PERMIT'NO. <br /> EH 13-24)REV. ;K 5) ^7 <br /> 3 ,_5�EH 14g 3V5 'I <br />