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` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT �i>7 <br /> 1601 E. HAZEL TON AVE., STOCKTON, CA 2r �,�C �{ <br /> Telephone (209) 466-6781 (� <br /> 1 . . <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED, ,_,,j.,r : , <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 /> , O� t� Diq <br /> Job(Address City Lot Size PM <br /> Owner's Name' t dress Phone <br /> Contractor's Name' - k se No. Phone v <br /> TYPE OF WELL/PUMP:• _i NEW <br /> ". WELL ❑ WELt•REPLACEMENT ❑ DESTRUCTION ❑ <br /> t z <br /> PUMP INSTALLATION_❑ SYSTEM REPAIR ❑ ; OTHER 0DISTANCE TO NEAREST: SEPTIC TANfK#r. 4 SEWER LINES l-,DISPOSAL FLD. PROP. LINE <br /> _ _ ...:Ste'"•-�_�...` <br /> FOUNDATION AGRICULTURE WELL f OTHER-WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA' CONSTRUCTION SPECIFICATIONS _1 } <br /> ❑ Inddstrial ❑ Open Bottom ❑ Manteca Dia, of Well Excavation t/Dia.iof Well Casing I/ <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy L Type of Casing I X Specifications <br /> . r-. , <br /> El Public � Ll Other." ❑­Qelta"" '""`T WDepth-of•Grout Seal .Typeof Grout <br /> _ _❑ Irrigation —Approx. Depth ❑ Eastern Surface Seal Installed by <br /> µRepair..Work Done-- ❑ L Type of:,Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> Depth I Filler Material {Belo ') I <br /> ,:.TY,PE 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 /> I <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK. -'.J❑ Type/Mfg Capacity No. Compartments <br /> PKG.TREATMENT PLT1 I <br /> ❑ Method of Disposal <br /> Distance to nearest: Well -N Foundation Proparty Line <br /> LEACHING LINE ❑ No. & Length of1ines Total length/size 7 <br /> FILTER BED r] Distance to nearesf: Well 6undation_�� Property Line <br /> s € f <br /> SEEPAGE PITS ❑ajDepth f -- Size Number. <br /> SUMPS Distance-to.nearest: Well cQddation 0 Property Line _ <br /> DISPOSAL PONDS ❑ <br /> hereby certify that I have prepared this application and that the work will beAon0n accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin LocaNbalth District.- N. '" <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."Contractors 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." c�s�'s• <br /> The applicant mut call far all required i tions. Complete drgting on remorse sidel�, r a� <br /> Signed Title: (�/ /- r Date: <br /> t. <br /> DEPARTMENT USE ONLY 1r <br /> Application Accepted if 4y A Date- Area10 <br /> "f <br /> I v <br /> Pit or Grout Inspection by Date �!z Final Inspection by 1_4pate -a$- <br /> Additional Comments: <br /> ❑ Stk 1.466-6781.❑•Lodi-369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return ail 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 iaas{REV"10183) <br />