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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA ; <br /> 1 Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> (Complete in Triplicate) <br /> Application is he+eby 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 /> +i City Lot Size PM <br /> Job Address <br /> Owner's Nam <br /> Address _ i " i= Phone <br /> c r <br /> Contra r Address Pb� , �i icense No.. fv Phone'"' � l <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ `DESTRUCTION ❑ + <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR>( OTHERI❑_, <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 El Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Dia, of Well Casing <br /> Type <br /> �DomesticlPrivate ❑ Grave! Pack ❑ Tracy T YP of Casing Specifications <br /> _— <br /> C'1 Public 17Other H Delta Depth of Grout Seal Type of Grout <br /> I Irrigation _.-Approx. Depth I I Eastern Surface Seal installed by <br /> Type of Pum State Work Done ' <br />. Repair Work Done V- TYP p� H.P. <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> t TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I I DESTRUCTION t I (No septic system permitted if public sewer is <br /> available within 200 feet,) <br /> Installation will serve: Residence_ Commercial` Other y tt <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. ❑ r. Method of p > <br /> Distance to nearest: Well Foundation Property Li w <br /> LEACHING LINE LI No. & Length of lines { Total length/size <br /> FILTER BED ❑ Distance to nearest: .Well Foundation Property Line <br /> SEEPAGE PITS Il Depth ' Size Number ENVIPONWNTAL HEACI H <br /> SUMPS L-1 Distance to nearest: Well Foundation Property Line r'SERVICF� <br /> DISPOSAL PONDS ❑ F <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 /> 1 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 must cal for all required i spections. Complete drawing on r verse side. <br /> Signed Title: Date: <br /> �7-3 <br /> 1 <br /> OR DEPARTMENT USE ONLY <br /> Application Accepted by Date / Area <br /> I Pit or Grout Inspection by Date final Inspection by en Date <br /> y r <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 /> FEEAMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> )NFO TI— ,►/� <br /> t.EH 13-241REY.5i85) C /� 7�`�� — 17 c'` -' <br /> EH 14-29 <br />