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l - APPLICATION FOR PERMIT h <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> t 1601 E. HAZEL T ON AVE., STOCKTON S <br /> Telephone (209) 466.6781 - CA <br /> PERMIT EXPIRES 1 YEAR FROM DATE ono �L <br /> rx >� <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 a f <br /> made in compliance with San Joaquin County Ordinance No.549 forsewage or No. 1862 for well/pump and the Rules and Regulations of the San J i <br /> Local Health District. PPlication is <br /> li ,!i . <br /> . Joaquin • <br /> Job Address - <br /> W city Lot Size PM <br /> z <br /> Owner's Name <br /> Phone LI 55 <br /> Contractor SEK-P— Address <br /> TYPE OF WELL/PUMP: License No. Phone y <br /> NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ } <br /> PUMP INSTALLATION ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK / SYSTEM REPAIR ❑ OTHER ❑ <br /> Y SEWER LiNES DISPOSAL F <br /> FOUNDATION AGRICULTURE WELL PROP. LINE <br /> WELL " <br /> INTENDED USE PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CO CT10N SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca4 <br /> Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack -❑ l <br /> ❑ Public Y Type of Casing Specifications <br /> N <br /> ❑ Other ❑ Delta Depth of Grout Seal <br /> [I Irrigation x. Depth ❑ Easter n Type of Grout <br /> Surface Seal Installed by <br /> Repair Work Done ❑ pe of P'mp }H.P. <br /> l D' meter State Work Done <br /> Well Destructi ❑ Wel <br /> Sealing Material {top 50'} <br /> Dept Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No stem septic System Y permitted if public sewer is <br /> Installation will serve: Residence i available within 200 feet.) <br /> Commercial_, Other a <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> SEPTIC TANK feet.- <br /> !Water table depth <br /> Type/Mfg " Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ <br /> t, Method of Disposal <br /> Distance to nearest: Well Foundation <br /> Property Line <br /> LEACHING LINE ❑ No. & Length of lines <br /> FILTER BED Total length/size <br /> ❑ Distance to nearest: Well Foundation <br /> Property Line <br /> SEEPAGE PITS ❑ Depth Size t' <br /> SUMPS Number 1 <br /> Distance to nearest: Well Foundation <br /> DISPOSAL PONDS ❑ Property Line <br /> 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 I <br /> employ an g� " rtify that in the performance of the work for which this permit is issued, I shall not ! <br /> P Y y person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or subcontracting signature <br /> certifies the following: "I certify that in the performance of the work for which this permit is issued, I steall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant m t ca11 for all required inspections. Complete drawing on reverse side. <br /> Signed � w <br /> Title: <br /> Date: <br /> �* FQR DEPARTMENT USE ONLY <br /> Application Accepted by V�}`� 1 3 <br /> Date Area <br /> Pit or Grout Inspection b Date <br /> Final Inspection by Date (� <br /> Additional Comments: 7 �d, 0 —` <br /> ❑ Stk 466,6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-M <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CK# `' <br />• INFO CASH RECEIVED BY DATE <br /> PEgMIT N0. <br /> + EH 13-24(REV. <br /> EH 1428 J� <br />