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APPLICATION FOR PERMIT <br /> SAN JOAaUIN LOCAL HEALTH DISTRICT <br /> � J <br /> 1601 E. HAZEL-TON AVE., STOCKTON, CA- <br /> Telephone (209) 466-6781 <br /> PERM.JT 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$'an 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 City MedLot Size PM <br /> Owner's Name t.Y"V � �-i <br /> Phone <br /> Contractor Address License No. Phone <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 CONSTRU ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Botto�'�::K, ell Excavation Dia. of Well Casing <br /> El Domestic/Private ❑ Gravel PackACasing Specifications <br /> D Public, El Othertf Grout Seal Type of Grout <br /> ❑ Irrigation Approx. Depth ❑ Eastern Surface'Seal Installed by qq <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ 'V <br /> Well Destruction ❑ Well Diameter. Sealing Material (top 501 <br /> Depth Filler Material (BelowfiO') (n <br /> TYPE OF SEPTIC WORK: NEW INSTALL/,ATIO -RIEPAtlft7-ADDITION ❑`, DESTROCTION (,Vo 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 ❑ Type/Mfg Capacity Nci. Compartments <br /> PKG. TREATMENT PLT. ❑ `h4thod 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 T-Foundation- Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <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 wprfc will:be done in accordanc6E with San Joaquin county ordipances, state laws, and <br /> rules and regulations of the San Joaquin Local Health.District. .m. --- r- <br /> Home owner or licensed agent's signature certifies the following: "I certifj 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 applica ust cal equired i spections. Complete drawing on reverse side. <br /> Signed Title: dA A.!� Date: <br /> 1-DEPARTMENT USE ONLY <br /> Application Accepted by` Date l Area <br /> Pit or°Grout Inspection by Date Final Inspection by �� bate <br /> F' Additional Comments: 4 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 p Mantece 823-7104.- - ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 16M E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED <br /> RECEIVED BY DATE PERMIT'NO. <br /> (HEV.rise( <br />