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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT 00 <br /> 1601 E. HAZEL T ON AVE.' STOCKTON CA <br /> t <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) {,Vt" <br /> k <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 Cotinty Ordinance No. 549 fpr.sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. I,C <br /> Job Address _ City Lot Size PM <br /> i <br /> Owner's Nameddress n Phone <br /> ontractor Address f/ icense No. Phone <br /> PE OF W /PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> O-NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OT <br /> INTENDED USE TYPE OF WELL POBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial ❑ Open Bottom ¢Manteca Dia. of Well Excavation Dia. of Well Ca ing <br /> Domestic/Private ❑ Gravel Pack .U'Tracy Type of Casing Specifications <br /> Public Cl Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i <br /> I I Irrigation _Approx. Depth I I Eastern Surface Seal Installed by <br /> epair Work Done ❑ Type of Pump H.P, State Work Done_ <br /> ell Destruction ❑ Well Diameter Sealing Material (top 50') 1 <br /> Depth Filler Material (Below 50') V 1 <br /> YjE.OF TION 1'1 REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if ublic sewer is <br /> available within 200 feet.l <br /> ' k Install tion will serve: Residence_ Co mercial_ Other <br /> Numb r of living units: Number of�� ee`�rooms <br /> Chara er of soil to a depth of 3 feet: Water table depth i <br /> EPTIC ANK ❑ Type/Mfg '# - -- -- - No. Compartments <br /> KG. T ATMENT PLT. ❑ od of Disposal <br /> Distance to nearest: -well� undation Property Line <br /> 4` <br /> EACHI G LINE ❑ No. & Length o%lines Total length/size <br /> ILTER ED ❑ Distance to near st: Well ndation Property Line <br /> EEPAG- PITS 1 Depth Siz ' _ Number <br /> UMPS Ll to nearest: IE � ndation Property Line <br /> ISPOSAL PONDS ❑ <br /> I rk a done in accordance with San Joaquin county ordina es, state laws, and <br /> hereby certify that I have prepared this application and that the <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 ontracting signature <br /> 1 certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to rkman's compensa- <br /> tion laws of California.dift " <br /> - - j <br /> l <br /> ,Signed A Title- Date: <br /> FOR DEPARTMENT USE ONLY i <br /> t Application Accepted by f _... 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 2W9, Stk., CA 95291 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK I RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> +.EH 1 44REV.i <br /> EH 14- f <br /> I <br />