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APPLICATION FOR'PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 Q ,. �' �� City of Size PM <br /> Owner's Name Address Phone ^� <br /> oe— <br /> Contractor's Name License No. � S` l " *� Phone✓ <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <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 ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout { <br /> ❑ Irrigation ---Approx. Depth ❑ Epstern Surface Seal Installed by Q <br /> Repair Work Done ❑ Type of Pump �`` H.P. lz State Work Done –ems <br /> 01 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 0 <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 /> ' 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: a * Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity "`'';�'No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal 0 <br /> Distance to nearest: Well Foundation Property,Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest Well Foundation Property Line <br /> k s� <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ ." <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 /> 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 Califor'nia."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 inspections. Complete drawing on.reverse side. <br /> Signed X � ��c _ Title:09R!! � Date: ' 9'prs �- <br /> FOR DEPARTMENT USE ONLY <br /> �J <br /> Application Accepted by Date Area <br /> Pit or Grout Inspection by Date inal Inspection by <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 DUE AMOUNT REMITTED CASH <br /> RECEIVED BY DATE PERMIT"N0. <br /> INFO <br /> +EH 13.24 ISM 10/831 <br /> EH 1428 <br />