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C' 36-1 <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA ��1� � <br /> Telephone (209) 466-6781 <br /> R <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED $OJ <br /> (Complete in Triplicate) ;� �N <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work her n des ibed. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 fo-r sewage or No. 1862 for well/pump and the Rules and Regulations of'(he1Sadjdiquin <br /> Local Health District. <br /> Job Address City R � <br /> � Size PM <br /> Owner's Name Address _Sr �� a Phone <br /> Contractor Z l Address License No. 3 2 Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR fjR- 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 /> VDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> fJ Public ❑ Other F1 Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation ­ApproK. Depth l I Eastern Surface Seal Installed by <br /> Repair Work Done IC' Type of Pump �.t�� H.P. State Work Done t <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') pV <br /> Depth Filler Material (Below 501 V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIRIADDITION ( I DESTRUCTION l I (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 No. Compartments <br /> PKG. TREATMENT PLT. ❑ , _Method of Disposal Qr <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 /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <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 Diltrict. <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'tb 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 issued,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The apo t m t call for all req inspect' Co lets drawing on reverse side. <br /> Signed X 'Title: - Date449� <br /> : <br /> OR �P TIVIENT USE ONLY j <br /> Application Accepted by �"� Date Area ✓ <br /> Pit or Grout Inspection by Date Final Inspection by Date <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 /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT-NO. <br /> + EH 13-241REV.I/A5I <br /> EH 14-2e <br />