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y r , <br /> 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 i <br /> made H 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. � s <br /> !I <br /> ' Job Address <br /> City Gf'i '' "' Lot Sizef��xi <br /> < L! PM <br /> Owner's Name <br /> ddress <br /> Phone <br /> Contractor <br />` Address <br /> TYPE OF WELL/PUMP: NEW WELL LJ WELL <br /> No. Phone <br /> PUMP INSTALLATION ❑ WELL REPLACEMENT ❑ DESTRUC�T10fJ,❑ <br />� DISTANCE TO NEAREST: SEPTIC TANK SYSTEM REPAIR ❑ OTHER ❑ <br /> SEWER LINES �__� DISPOSAL FLD. <br /> FOUNDATION AGRICULTURE WELLPROP. LINE <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> L] Industrial ❑ Open Bottom �� <br /> ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel PackDia. of Well Casing <br /> ❑ Tracy Type of Casing" <br /> (l Public F1 OtherF1 Delta Specifications 4J <br /> ,o. <br /> . I I Irrigation �,.Approx. Depth f I Eastern Depth of Grout Seal Type of Grout <br /> Repair Work Done ❑ Type of Pump -! Surface Seal Installed by v <br /> _ \ <br /> Well Destruction ❑ Well Diameter ! H.P. State Work Done_ <br /> Sealing Material (top 50') <br /> Depth Filler Material l6elow 50'1 <br /> TYPE OF SEPTIC WORK: NEW INSTALIATION.l.1 REPAIR/ADDITION IJ DESTRUCTIO ] IN septic system permitted if public sewer is <br /> Installation will serve: Residence 'Cortlmercial_ Other available within 200 feet.l <br /> I - <br /> Number of living units: Numberl`of bedrooms <br /> Character of sod to a depth of 3 feet: f <br /> SEPTIC TANK ❑ Type/Mfg _- Water table depth <br /> PKG. TREATMENT PLT. ❑ hCapacity No. Compartments <br /> Distance to nearest: Well Method of Disposal <br /> Foundation Property Line <br /> LEACHING LINE 0 No. & Lengthof lines <br /> FILTER BED LJDistance to nearest: Well Total length/size <br /> a <br /> Foundation Property Line <br /> SEEPAGE PITS I i Depth �l <br /> SUMPS Size Number <br /> ❑ Distance to nearest: Well <br /> DISPOSAL PONDS El Foundation Property Line <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 <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 1 shall not s <br /> tion laws of California.^, Performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> s <br /> The applicant must call for all re wired ' s ions. Complete drawing on reverse side. <br /> X Signed X <br /> Title: V <br /> Date: l <br /> II FOR DEPAR MENT USE ONLY <br /> Application Accepted by <br /> Date Area <br /> . Pit or Grout Inspection by <br /> Date--,—�� Final Inspection by 7y���y�� <br /> Additional,Co. rit ts: Date <br /> IJ <br /> Stk 466-6781 ❑ Lodi 369-3621 „ ❑ Manteca :11 823-7104 ❑ Tracy 835 6365 <br /> Applicant Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 85201 ` <br /> FEE AMOUNT DUE <br /> INFO AMOUNT REMITTED CK CEIVED EIY <br /> A REBATE PERMIT Np, <br /> + EH 13-24(REV,r i s7 � - `�� <br /> EH 14'28 >, cJ� <br />