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APPLICATION FOR PERMIT <br /> I SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> ' Telephone (209) 466-6781 <br /> PERMIT EXPIRES 9 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 heiein described. This application is <br /> made in compliance with San Joaquin County Ordinance No. 549 for sewage or No. 1852 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address , CitylgnA�LLot' <br /> Size <br /> PM <br /> r' Owner's Name Address �( ��( [L, r�] _ Phone <br /> Contractor , Address <br /> 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 <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATIONg AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OFWELL', PROBLEM AREA CONSTRUCTION SPECIFICATIONS v <br /> �❑ Industrial ❑ Open Bottom M © Manteca Dia. of Well Excavation . <br /> Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 71 Public n Other 1-7 Delta Depth of Grout Seal A <br /> Irrigation Type of Grout <br /> I 1 lrri <br /> t1 _-Approx, Depth { 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 50') � <br /> Depth <br /> Filler Material (Below 50') <br /> TYPE OF'SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I 1 DESTRUCTION (No septic system permitted if pu4se-eris <br /> available within 200 feet.) <br /> Installation will serve: Residence— Commercial_ Other � <br /> Number of living units: Number of bedrooms <br /> I <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK; ❑ Type/Mfg Water table depth <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> Method of Disposal <br /> Distance to nearest: Well Foundation Property dine <br /> LEACHING LINE ❑ No. & Length of lines <br /> Total length/size <br /> FILTER BED ❑ Distance to nearest: Well <br /> Foundation Property Line - <br /> SEEPAGE PITS ` I i Depth Size. _ .) <br /> Number <br /> SUMPS ❑ Distance to nearest: Well Foundation <br /> Property.Line <br /> DISPOSAL PONDS L11 <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, a r <br /> rules and regulations of.,the.San Joaquin-Local-Health Di$trict: "F ._ <br /> Home owner or licensed agent's signature certifies the following: ',I certify that in the performance ofthe work for which this permit is issued, I shall no <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signatur <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 comjfe <br /> tion laws of California." <br /> The applicant must call for all required inspections. Completewin <br /> drag on reverse side. <br /> Signed XX/ w Title: <br /> — Date: 1- 13— <br /> FOR <br /> 1` 13—FOR DEPARTMENT USE ONLY <br /> Application Accepted by ate <br /> D <br /> -- Area `.., <br /> Pit or Grout Inspection by Dots. Final Inspection by <br /> ate—, <br /> Additional Comments: <br /> ❑ Sik 466-6781 ❑ Lodi- 369-3621 Cl 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 35201 <br /> FEE AMOUNT DUE AMOUNT REMITTED i <br /> INFO CASH RECEIVED BY DATE <br /> PERMIT'NO. <br /> a.EH 19-241REV.tifasl '�>S <br /> EH 14-28 <br />