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I <br /> APPLICATION FOR PERMIT t <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTf ` <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 'L - <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 City Lot Size PM <br /> Owner's Name Address Phone <br /> t <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 CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial 4 ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> n Public ❑ Other Cl Delta Depth of Grout Seal Type of Grout — <br /> 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 /> i <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION r (No septic system permitted if public sewer is <br /> available within 200 feet.), <br /> i <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Numberofbedrooms <br /> Character of soil to a depth of 3 feet: i Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity 4 No. Compartments + <br /> PKG. TREATMENT PLT. ❑ Method of Disposal t <br /> Distance to nearest: m' -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 € Numb e^ � - �-- <br /> SUMPS C1 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 st 11 for all required i spec'ons. Complete drawing on reverse side. <br /> oe <br /> Signed X Title: ( Date: <br /> FOR DEPARTMENT USE ONLY i <br /> Application Accepted by Datea / A ea / <br /> Pit or Grout Inspection by Date Final Inspection by I Date <br /> 2. <br /> --Additional,Comments:�"��'� <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 82377104 E)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 CASH RECEIVED BY DAT5 PERMITNO. <br /> + EH 13-24)REV.t j�Z7 P7-3-7/ <br /> EH 14-26 l-G✓I��� <br />