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APPLICATION FOR PERMIT _ <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' , t ( 3 <br /> rf <br /> ^/ 1601 E. HAZELTON AVE., STOCKTON, CA <br /> C� J <br /> Telephone (209) 466-6781 -) <br /> PERMIT EXPIRES TYEAR FROM DATE ISSUED <br /> 'NVIIiCr,�€ �- <br /> (Complete in Triplicate) AL HEALT <br /> E t1MA application is <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work er t. <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 /> r' <br /> Job Address <br /> City -2� � Lot Size PM <br /> Owner's Name Address <br /> Lhone <br /> Contractor <br /> Address License NoAL � ) Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION,+, SYSTEM REPAIR 41l111111= OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL _ OTHER WELL PITS/SUMPS <br /> _ r <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS 1 <br /> El Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> Type of CasingSpecifications <br /> 9 Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Grout — <br /> M Public F1 Other ❑ Delta Depth of Grout Seat <br /> I I Irrigation ­Approx. De th I I Eastern Surface Seal Installed by <br /> Repair Work Done i4 Type of Pump — H.P. State Work Done--� <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION l 1 REPAIR/ADDITION t I DESTRUCTION I I (No septic system permitted if public sewer is r1` F � <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 r <br /> SEPTIC TANK El Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ElMethod 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 I I Depth Size _ Number <br /> SUMPS Ll Distance to nearest: Well Foundation Property Line <br />- fltSPASAt-i'ONDS ❑ <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 /> that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "1 certify <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,I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mr- <br /> OR <br /> call r all rd inspections. Complete drawing on reverse side. <br /> Signed X � ��� C� )./Title- Date: ° a <br /> DARTMENT USE ONLY <br /> Application Accepted by Date ��` CL_ Area <br /> Pit or Grout Inspection by <br /> Date Final Inspection by '' Date <br /> Additional Comments: <br /> El Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 El Tracy <br /> 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 fAMOUNTTDUE AMOUNT REMITTED CASH CK 9 RECEIVED BY DATE PERMIT'NO. <br /> INF <br /> + EH 13-24(REV.i/H 5) aff� <br /> EH 14-26 <br />