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-� <br /> Al <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HACELTON AVE., STOCKTON, CA <br /> "Telephone (209) 466.6781 <br /> PERMIT EXPIRES 7.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 .3 i <br /> City ���N Lot Size PM <br /> e Owner's Na Address ; <br /> t <br /> Phone "��4 � <br /> Contractor Address License No. 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 /> f <br /> Ll Industrial O Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private C Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation _Approxi Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material !Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is Y <br /> ailable 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 X Type/Mfg! Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> f <br /> LEACHING LINE ❑ No. & Length of lines fI Total length/size '& <br /> FILTER BED ❑ Distance to nearest: Well Foundafion Property Line``' <br /> SEEPAGE PITS ❑ Depth Size Number -, Kl <br /> SUMPS ❑ Distance to"nearest: Well Fourldatioll-- ` ' Property Line .t <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be donelwaccolyance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquini Local Health District.. , <br /> Home owner or licensed agent's signature certifies the fallowing: "I ceriify,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 iawg.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 mu t call for all requi ed inspections. Complete drawing on reverse side. <br /> Signedr� <br /> Title: 'Date: 3�- <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byAtA �- an <br /> Date I Area <br /> Pit or Grout Inspection by Date Final-Inspection'by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369 1 ❑ Manteca 623-7104 ❑ Tracy 885 6385' <br /> Applicant - Return all copies to: Environ ental Health Permit/Services.1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED CK = RECEIVED BY <br /> INFO 1 CASH DATE PERMIT-NO. <br /> +'EH13-241REV.1i851 <br /> EH 1428 `-�✓ <br />