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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 /> 41 (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 City + ` + Lot Size PM <br /> t <br /> Owner's Name _. r`' Address'— uPhone <br /> Contractor [ A&- fi 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 FL_D. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS C i <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Pia. of Well Casing <br /> i ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications i <br /> i <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> I ❑ Irrigation ---Approx. Depth _ :❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction C] Well Diameter Sealing Material Itop 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 /> j a available within 200 feet.) <br /> Installation will serve: Residence-_ Commercial. Other <br /> F <br /> Number of living units: Number of bedrooms <br /> f Character of soil to a depth of 3 feet: I Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity—O No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> } r <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS' ❑ Depth Size Number. <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> DISPOSAL PONDS ❑ <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 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 followi certif hat 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 Califo nia." <br /> The applicant mu t al r r quired inspections. Complete drawing on reverse side. <br /> Signed X HF Title: _8 - <br /> __ Date: l— f <br /> FOR DEPARTMENT USE ONLY <br /> 4 Application Accepted by Date 15 1 Area `�- <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date A <br /> Additional Comments: <br /> /v o <br /> ❑ Stk 466-6781 ❑ Lodi 3694211 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2008, Stk., CA 95201 ` <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO [ CASH 1�] <br /> + EH 13-24(REV:1/85) '�'� �L/� ��/�� 3�` <br /> EH 14-26 <br />