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APPLICATION FOR PERMIT CSS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED � i � <br /> (Complete in Triplicate) �,�r <br /> I. <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 /> Q . i <br /> Job Address �/ City Lot Size PM <br /> r I� <br /> Owner's Name _� Address ®3� J <br /> Phone <br /> Contractor Address . +" } ; <br /> License No. Phone_ <br /> TYPE OF WELL/P MP: NEW WELL I] r t5 " WELL REPLACEMENT ❑ 1 DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ _ SYSTEM REPAIR ❑ OTHER ❑ ; <br /> DISTANCE TO NEAREST: SEPTIC TANKSER LINES" ' L ISPOSAL FLD. PROP. LINE <br /> FOUNDATION f + AGRI LTURE WELL . OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA�C`( NSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Diia7rof Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack © Tr-- pe p Casing Specifications <br /> I-i Public Ll Other ❑ DeltaDepth of G ut Seal Type of Grout _ <br /> I I Irrigation ---Approx. Depth I I Eastern"-1 Surface Seal Installed by 'F F <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter f Sealing Material (top 50') <br /> Depth R Filler Material (Below 50') ' <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION la REPAIR/ADDITION 1 l DESTRUCTION 'fNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: - Residence 1/Commercial_ ,Other u <br /> Number of living units: Number of bedrooms N � � <br /> Character of soil to a depth of 3 feet: r f <br /> Water table depth <br /> SEPTIC TANK ❑. Type/Mfg i Capacity No. Compartments <br /> PKG. TREATMENT PLT.O Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> y � r <br /> LEACHING LINE ❑ No. & Length of lines. Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> i <br /> SEEPAGE PITS I I Depth 1 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, and <br /> rules and regulations of the San Joaquin Local Health District"TA I ..,. <br /> Home owner or licensed agent's signature certifies the following: '1 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." I j <br /> The applicant must c for all requi ed ` s ons. Complete drawing on reverse­sida."'r"`�"` <br /> Signed Title: f <br /> ..- Date: <br /> ORO R E SE ONLY + <br /> c _ <br /> Application Accepted by Date �� - Area <br /> Pit or Grout Ins cti by Date Final Inspection by Date <br /> Additional C ants: <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 /> i <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK A RECEIVED BY DATE PERMIT'NO. <br /> t EH 1324 IREV.t i H 5] ,�� <br /> EH 14-28 <br />