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�r <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br />` Telephone (209) 466-6781 <br /> PERMIT EXPIRES I YEAR FROM DATE ISSUED <br /> 42-10 (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.foaquin 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. Coe <br /> f Ci Lot SizeC404f PM <br /> Job Address � l <br /> LJ1 <br /> Owner's Na <br /> —I �� <br /> Address Phone <br /> I <br /> Phone <br /> Contractor's Name <br /> TYPE OF WELL/PUMP: NEW WELL 13 WELL REPLACEMENT LlDESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ElOTHER D <br /> I 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 pia. of Well Casing ' <br /> ❑ Industrial ❑ Open Bottom ED Manteca Dia. of Well Excavation <br /> Type of Casing Specifications <br /> El❑ Domestic/Private D Gravel Pack Tracy --k Grout <br /> Grout Seal T <br /> ❑ Public ❑ Other ❑ Delta Depth of <br /> ] ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> ` Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction D Well Diameter Sealing Material (top 501 s <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic thin ymitted if publicsewer is <br /> availabInstallation will serve: Residence— Commercial Other f <br /> Number of living units: Number of bedrooms Water table depth 1 <br /> Character of soil to a depth of 3 feet: , <br /> SEPTIC TANK E3 Type/Mfg Capacity No. Compartments <br /> r <br /> � Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> a LEACHING LINE ❑ No. & Length of lines <br /> F Total length/size # <br /> FILTER BED ❑ Distance to nearest: Well. <br /> Foundation Property Line r <br /> Number <br /> ., — <br /> � SEEPAGE PITS " Depth Size <br /> SUMPS El Distance to nearest: Well .4fW_ Foundation Property Line .— <br /> DISPOSAL PONDS ❑ t`�"` '` <br /> Thereby certify that I have prepared this application and'that the-work will be done,in-accordance with.San Joaquin.-county ordinarices,}state laws, and <br /> District. <br /> rules and regulations of the San Joaquin Local Health <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 parson in such manner as to become subject to workman's cpmpensation�laws-of California.'.'Co6tractor„s hiring or sub-contracting signature <br /> certifies the following:"I certify that in the; rformance,of the work for which thiCpermit-is-issued;4 slia'll employ persons subject to workman's compensa <br /> tion laws of Calit nia." <br /> The applican u call r all re i di spections. Complete drawing on reverse side.OfElO <br /> Title: Date: <br /> Signed fi <br /> i FOR DEPARTMENT USE ONLY <br /> Date Area <br /> Application Accepted by <br /> O <br /> i <br /> Pit or Grout Inspection by <br /> Date g Final Inspection-by Date <br /> Additional Comments: <br /> q <br /> ❑ 5tk 466-6781 ❑ Lodi 369-361t ❑ Manteca 823-7104 ❑ Tracy 835-885 <br /> Applicant- Return all copies to: Environmental Health Permrt7Services 1601 E.,Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE CK RECEIVED BY DATE jPFR1M11Y0N]0 'INFO AAM7OUNT DUE AMOUNT REMITTED CASH+EH 13-24 4REV.10!631 f� �a <br /> EH 14-26 -- �, <br />