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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 <br /> City KA�Lo"t Size—,3 - PM <br /> Owner's Name Address Pa f � <br /> hone <br /> Contractor 2 dress (> d� n <br /> License No! Phone / D� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> Or <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. P INE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFIC S <br /> ❑ Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excav Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of ng Specifications <br /> ❑ Public ❑ Other ❑ Delta pth of Grout Seal Type of Grout <br /> ❑ Irrigation —J�pprox. Depth ❑ Easter Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction <br /> El Diameter Sealing Material (top 50') <br /> Dept Filler Material(Below 501 <br /> TYPE OF=serve: <br /> EW INSTAL TION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ INo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installadence_ Commercial— Other <br /> Number of living units:T 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. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Fgundation Property Line <br /> ACHING LI -K-No. & Length of lines <br /> �otal length/size <br /> FILTER BED ❑ Distance to nearest: Wel � Foundation <br /> SEEPAGE PITS Depth L Size umber <br /> UMP ❑ 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 be done in accordance with San Joaquin county ordinances, state laws, and <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 t c I uire ,in pections. C m ete drawingon side. �s <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b . d <br /> / Date 1 s — Area Q <br /> or Grout Inspectio y Date b Final Inspection by <br /> Date <br /> Additional Comments: < <br /> ❑ Stk 466-6781 ❑ Lod) 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 gMOUNT DUE AMOUNT REMITTEDCK <br /> INFO CASH RECEIVED BY DATE PERMIT"N0. <br /> + EH 13-24(REV.1/85) �© ` <br /> EH 1428 <br />