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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA N O W 0 <br /> Telephone (209) 466-6781 %,�p � / h <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED MD , W� <br /> (Complete in Triplicate) ' <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or instait the work herein described. This application r�s <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. y� <br /> Job Address L.. , <br /> y h City Lot Size PM <br /> Owner's Name Address -731� _4; 1�/ <br /> Phone [ W 3 <br /> Contractor Address <br /> TYPE OF WELL/PUMP: Phone <br /> NEW WELL License No.❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLp. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL <br /> INTENDED USE OTHER WELL PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br />" ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> 11Domestic/Private ElGravel Pack 13 Tracy T Dfa. of Well Casing <br /> ype of Casing f- Specifications <br /> ❑ Public LlOther ❑ Delta Depth of Grout Seal P- <br /> ❑ Irrigation Type of Grout <br /> g —._Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter _Sealing Material (tap 501) <br /> Depth Filler Material (Below 501) ' Q <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> Installation will serve: Residence— Commercial— Other available within 200 feet.) <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANKWater table depth <br /> ❑ Type/Mfg Capacity <br /> PKG. TREATMENT PLT. C1 No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS Number <br /> ❑ Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ 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 /> rifles 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 applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date:3L7' . <br /> FOR PARTMEN�USII ONtY /�Application Accepted by ti�flrnb. _ Date t1� <br /> Area <br /> Pit or Grout Inspection by D to Final Ins . 7%• <br /> Inspection by Date <br /> Additional Comments: <br /> Cl Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 7104 ❑ Tracy 835-6385 <br /> Applicant-Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 5201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK <br /> INFO } CASH RECEIVED BY DATE PERMIT•NO. <br /> EH 124{REV.I/B 51 99 <br /> EH 14-4-Ze S � ,,� <br />