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APPLICATIONFOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT t <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA ��W <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 'I YEAR FROM DATE ISSUED � <br /> 1 <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 ' 1G City tot Size PM <br /> Owner's Name Address Address Phone <br /> Contractor CIV44e,*` 66t 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 /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA . CONSTRUCTION SPECIFICATIONS E <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy TypeofCasing Specifications <br /> i <br /> M Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout _ <br /> I I Irrigation —.-Approx. Depth f I 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')I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION IJ DESTRUCTION (No septic system permitted if public sewer is <br /> i available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other I <br /> a <br /> Number of living units: Number of bedrooms j <br /> Character of soil to a depth of 3 feet: t. f Water table depth <br /> -SEPTIC TANK ❑ Type/Mfg Capacity`i" n No. Compartments j <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 I <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line I <br /> SEEPAGE PITS I I Depth— --Size y _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> 1 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 regulatio the San Joaquin Local Health District. <br /> Home owner or li n d gent'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 pers i s c m at as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> certifies the folio : 'I e y 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 Cali ia.' <br /> The applicant m re fired inspections. Complete drawing on r rse side,.�� = <br /> Signed X Title Date: <br /> Date: <br /> 1 <br /> R TMENT USE ONLY j <br /> n � <br /> Application Accepted by � - `mss` � Date _5� 3 Area � <br /> Pit or Grout Ins f 441 i Date I <br /> Inspection by Date Final Inspection by <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 CK H RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV.1/e 5) <br /> EH 14-2e 172 '��� <br />