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k <br /> APPLICATION FOR PERMIT <br /> t SAN JOAQUIN LOCAL HEALTH DISTRICT r 1 <br /> 1601 E. HAZE 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. 1 <br /> City Lot Size PM <br /> Job Address �} <br /> r tom; Phone <br /> Owner's Name Address <br /> / <br /> Contractor <br /> Address License No./2,?—�Phone <br /> TYPE OF WELL/PUMP: NEW WELL CI. WELL REPLACEMENT El DESTRUCTION C] <br /> PUMP INSTALLATION ❑- SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELD PROBLEM AREA CONSTRUCTION SPECIFICATIONS , <br /> ❑ Industrial ❑ Open Bottom C1 Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Type❑ Domestic/Private ❑ Gravel Pack � ❑ Tracy � YP of Casing / .11 Specifications i <br /> ❑ Other ❑ Delta Depth of Grout Seal Type of Grout — <br /> ❑ Public y I' <br /> I 1 Irrigation Approx. Depth [\Eastern Surface Seal.-Installed by --- <br /> Repair Work Done 11Type of Pump N'` H P. sf State_Work_Rone�- <br /> Welk Destruction ❑ Well Diameter ing Mate;ial'Itop 501 t <br /> Depth <br /> Filler Ma (Below 501 l <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIR/ADDITION i I STRUCTION (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will server Residence Commercial ther ) r <br /> s <br /> Number of living units: Number of bedroorns <br /> ter table depth <br /> Character of soil to a depth of 3 feet: '�df j <br /> rCapacity f No. partments <br /> SEPTIC TANK ❑ 'Type/Mfg <br /> I <br /> 1Vl <br /> PKG. TREATMENT PLT. F) ine <br /> / �La�f 'sposal <br /> Distancet'nearest: Well Foundation —Property Line <br /> LEACHING LINE u ❑ No&!rLength of lines _.. 4 `'Total`F , Pro/size— <br /> FILTER <br /> size F)LTER BED Distance to nearest: Well Foundation Property Line \� <br /> SEEPAGE PITS l 1 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line , l <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, ander[ i <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 /> mpensation laws of California." Contractor's hiring or sub contracting signature <br /> employ any person in such manner as to become subject to workman's co <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 it f all requir d in pections. Compl to drawing on reverse side. <br /> Signed X Title: /, Date: <br /> # FOR DEPARTMENT USE ONLY <br /> ~ <br /> Application Accepted by Date �- ^ 2_ Area d <br /> . <br /> fDate -7 I"QI <br /> Pit or Grout Inspection by <br /> Date Final Inspection by <br /> Additional Comments: <br /> t ❑ Stk 466-6781 ❑ Lodi -3621 ❑ Manteca 823-7104 d Tracy 835-6385 C L- Al <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> t EH 13-24 iREV.1/H 51 (1 i v <br /> EN 14-2a V <br /> M- <br />