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P , <br /> 41 <br /> �� M <br /> n <br /> Y APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON 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 4 o 0141 Lot Size PM <br /> Owner's Name1 -� _ Address Phone <br /> C !� <br /> Contracts Addres V E— . A-'License 4t���Phon <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. PR <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USETYPE OF WELL PROBLEM AREA CONSTRUCTION SP TIONS <br /> ❑ Industrial © Open Bottom ❑ Manteca Dia. of cavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy pe of Casing Specifications <br /> ('1 Public IF] Other 17 Del - Depth of Grout Seal Type of Grout _. n <br /> I I Irrigation Approx, Dept Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of H.P. State Work Done_ <br /> Well Destruction ❑ e I Diameter Sealing Material Itop 50'1 <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I I DESTRUCTIONo septic system permitted if public sewer is <br /> vailable within 200 feet.i <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. ❑ t Method of Disposal <br /> 1 <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 ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS LJ <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 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 applican must call for all required inspections. Complete drawing on rse sid <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY !!`` C <br /> Application Accepted by date V '" V Area <br /> Pit or Grout Inspection y Date � Fin�I Innspection by Dat <br /> Additional Comments: �r/`y r "'tee' �I� <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 <br /> INFO AMOUNT DUE AMOUNT REMITTED .CK RECEIVED BY DATE PERMIT"NO. <br /> ♦ EH t3-24 1REV.5 i k 51 C r� �F ��^G� <br /> EH 1426 I t r <br />