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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 f <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 / H - City 14 Lot Size PM <br /> Owner's Name Address Phone <br /> d — 3 jf� <br /> Contractor Address �� License fJv 5 f Phone / ✓� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ n <br /> PUMP INSTALLATION.❑ ., SYSTEM REPAIR ❑ - OTHER ❑ a <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS ` t <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS �} <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia- of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 1'1 Public ❑ Other f 1 Delta Depth of Grout Seal Type of Grout <br /> I t Irrigation --Approx. Depth # 1 Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50 ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION 1 I DESTRUCTION I INo septic system permitted if public sewer is <br /> vailable within 200 feet.) I <br /> Installation will serve: Residence_ Commercial_' Other 1 <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: ` Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size- <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ i <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: -- ­ --- - - - ^ i <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."Contractors hiring or sub-contracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued,1 shall employ persons su ct to workman's compensa- <br /> tion laws of California." r <br /> The appV��g <br /> r all requir Complete drawing on reverse side. <br /> }[ Signed Title: Date: � / <br /> FOR DEPARTMENT USE ONLY �j <br /> I s` C "� i <br /> Application Accepted by ' DateArea 412 <br /> Pit or Grout Inspection,.by G� Date Fin I I s bye to <br /> Additional Comment <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 ? <br /> Applicant - Return atl copies to: Environmental Heatth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE / <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH1324tREV.tiH5l -4 s� "I r J <br /> EH U-29 ��..!! 111 d� <br />