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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON 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 WA City-- Lot Size PM <br /> Owner's Name -Address ` L` Phone <br /> Contractor Address License No. &Im�Phone <br /> TYPE OF WELL/PUMP: WIEW 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 /> N'bomestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> F1 Public ❑Other n 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 <br /> Well Destruction ❑ Depth Well <br /> Diameter Sethi Materialri Below a01f - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTIO ,,l I;(No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other f , <br /> Number of living units: Number of bedrooms _ <br /> Character of soil to a depth of 3 feet: / Water table depth <br /> ZI— <br /> SEPTIC TANK ❑ Type/Mfg Capacity ' No. Compartments—;'°'" <br /> 4�1. <br /> PKG. TREATMENT PLT. ❑ ~` Method of Disposal <br /> Distance to nearest: Well Foundation' P rty Line <br /> ope <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size _ _ Number <br /> SUMPS Ll Distance to nearest: Well ,_ Foundation Property Line <br /> DISPOSAL PONDS ❑ - <br /> I hereby certify that I have prepared this application and that) work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health Di§trict. <br /> Home owner or licensed agent's signature certifies the followipq;`i'l certify that in the performance of the work for which this permit is issued, 1 shall not <br /> employ any person in such manner as to become subject to vk.4 kman'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 re qui tions. Complete drawing on reverse side. <br /> Signed X Title: '— Date: <br /> FOR DEPARTMENT USE LY <br /> Application Accepted by Date -/4/ Area <br /> Pit or Grout Inspection by Date Final Inspection by�/S�- Dated' 011_�7 <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 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK V RECEIVED BY DATE PERMIT'NO. <br /> + EH 14-24(REV.i/x 5) <br /> EH 14-28 _;S'00 <br />