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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> �- PERMIT EXPIRES 1YEAR 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 2— City ~ Lot Siz PM <br /> Owner's Name Address Phone <br /> Contractor K � "-dress License No. - `" Phone? <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWE ES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGPXULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBE AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Ma teca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ T a Type.of Casing Specifications <br /> FI Public ❑ Other ❑'belt Depth of Grout Seal Type of Grout _._ <br /> I I Irrigation _.Approx. Depth I I East rn Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done_ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material ('Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION II]EST CTION i (No septic system permitted if public sewer is 1 <br /> a ila e within 00 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: to d <br /> SEPTIC TANK ❑ Type/Mfg Capacity No ompartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ell Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size (� <br /> FILTER BED ❑ Distance to nearest: V <br /> I --_ Foundation Property Line f <br /> SEEPAGE PITS I I Depth Size Number <br /> '1 <br /> SUMPS Cl Distance to near t: Well Foundation Property Line 1r <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 Diktrict. <br /> Home owner or licensed agent's signature certifies the following: "1 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 C lifornia." <br /> The applican ust call for require inspections. Complete'drawing on er�' <br /> Signed X `^ Title: I Date: <br /> i <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted b 4kDate 72,1Area <br /> Pit or Grout Inspection b Date Final Inspection by p U _ Date <br /> Additional Comments: �� � f aU6 <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-638 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE <br /> INFO AMOUNT DUE AMOUNT CASH <br /> CASH RECEIVED 8Y DATE �JPERMIT^N1O. <br /> i EH 13-24(REV.i i n 51 LT_> <br /> EH 14-26 <br />