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Y <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <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, <br /> Job Address <br /> 412Address <br /> Cit C of Size PM <br /> Owner's NamePhone <br /> r <br /> Contracto ,_ _Address C) l� g a License No!51�Z 6- - Phone�3�`���� <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. PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> >QDomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F] Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout—_. _ <br /> I I Irrigation ­Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done 'Type of Pump ___ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50'} <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I I DESTRUCTION I I Wo septic system permitted if public sewer is ? <br /> available within 200 feet.} <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 ❑ T e/Mf <br /> YP g Capacity � No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well <br /> Foundation Property Line r <br /> l <br /> LEACHING LINE ❑ No. & Length of lines Total length/size / <br /> FILTER BED <br /> ❑ Distance to nearest: Well Foundation Property Line <br /> 1 <br /> SEEPAGE PITS I 1 Depth SizeifNumber I <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will tie done in accordance with San Joaquin county ordinances, state laws, and f <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 applicant mu for all requtced inspections. Complete drawing on reverse side. <br /> Signed Title:TAAA. __ Date: Z �� <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by <br /> D_ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date d <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. Bax 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDCK 0 <br /> INFO ASH RECEIVED BY DATE PERMIT'NO. <br /> EH 13-24•.EH112BIRE'V.rixsl 1/wq0 <br /> { <br />