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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 J��44a,�1.urn C�Qunty Ordi ce No. 549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> L7TYPE <br /> lth District. �Yb � PrD <br /> ess City Lot Size PM <br /> Name Address . /�7 � ll� � Phone <br /> r Address LicenZe No. Phone_ <br /> WELL/PUM NEW WELL ❑ WELL REPLACEMENT ❑ "DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP:LINE <br /> FOUNDATION AGRICULTURE WELL OTHEB—W PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gra I`c. ❑ Tracy Type of Casing Specifications <br /> M Public Other ❑ Delta Depth of Grout Seal Type of Grout­—. ­ <br /> I <br /> rout _.I I Irrigation ---Approx. Depth I 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 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ll REPAIR/ADDITION t I DESTRUCTION (No 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 " No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line o <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 /> 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, an <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 /> e applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Q d /. Dater <br /> FOR DEPARTMENT USE ONLY �7 �Q <br /> Application Accepted by Date < � rJ _ Ar <br /> Pit or Grout Inspection by ate t Fin pection b� Date% <br /> Additional Comments: r `•' 0 1 <br /> Je f <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 AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO CASH <br /> ♦.EH/3.24(REV.1/x s) <br /> EH 14-28 lllJJl <br />