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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZETON4AVE., STOCKTON, CA 1 <br /> Telephone(209) 466-6781 <br /> PERMIT EXPIRES 1 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 herein described. This application is <br /> made in compliance with San Joaquin County Ordinancq No.549 for sewage or No. 1862 for well/pump and the Rylesand Regulations of the San Joaquin <br /> Local Health District. ! / ` r <br /> Job Address City Lot Size PM <br /> P•� <br /> 4 <br /> Owner's Name Address Phone' <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I PUMP INSTALLATION ❑ SYSTEM R PAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES � DISPOSAL FLD. PROP. LINE I <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> I <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia.of Well Casing <br /> i <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications S <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout i <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by J <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done I <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 1 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial— Other } <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. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line ` <br /> 44 17N <br /> LEACHING LINE X No. & Length of lines Total length/size �- <br /> FILTER BED' ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number C, <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line w <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."Contractors 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 emplgy persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant ust call for all required inspections. Complete drawing on reverse side. <br /> 1 <br /> Signed Title: QnAA!N� !Date: (� <br /> FOR DEP RTMENT USE ONLY ' <br /> F r '. � <br /> Application Accepted by J� Date r Area g <br /> Pit or Grout Inspection by r Date' Final lnspection y �� C2/�'` Dater � <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 /> a <br /> i <br /> IEEE AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. ' <br /> + EH 13-24(REV.1/s 5) ���� 1�00 I-L 1 OD <br /> EH 14-28 rrr - i V�✓ <br />