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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 7 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 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 /> Job Address P City F Lot Size ` C QV PM <br /> Owner's Name Address Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: —NEW.WELL. ❑a' WELL REPLACEMENT .❑, DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ — OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK- SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELLOTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF-WEL-L 'PROBLEM AREA CONSTRUCTION SPECIFICATIONS ;t <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy 'Type of casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material ftop 501 <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 4 D No. Compartments Z <br /> . PKG. TREATMENT PLT. ❑ � �,� �' Method of Disp_osa� �} , <br /> Distance to nearest: Well Foundation le "� Property Line <br /> LEACHING LINE No. & Length of lines Total length/size G V <br /> FILTER"BED ❑ Distance to nearest: WeII ClFaundation Property Line <br /> + SEEPAGE PITS ❑ .y Depth Size Number <br /> SUMPS ❑ Distance to`nearest: , Well Foundation Property Line <br /> DISPOSAL PONDS 71. <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 iis 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 applican u t call f required,inspections. Complete drawing on reverse side. a , <br /> Signed �� Title:_ Date: y <br /> FOR DEPA TMENT USE ONLY �� f <br /> Application Accepted by w f\ Date Area f _ <br /> Pit or Grout inspection by I Date Final Inspection by Date S <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 8355-6385 <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 RECEIVED BY DATE PERMIT"NO. <br /> INFO CASH <br /> +EH 13-241REV.1/55) <br /> EH 1426 <br />