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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 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 Ordinance No. 549 for sewage or No.-1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District Job AdoresCity Lot SizeC1/ PM <br /> Owner's Natt Address � , <br /> [d Phon , <br /> ContractAdd1 <br /> ress �, 2�2� k <br /> 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 SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> M Public n Other Cl Delta Depth of Grout Seal <br /> Type of Grout <br /> I I Irrigation --Approx. Depth I) Eastern 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 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION i I DESTRUCTION ( I (No septic system permitted if Public sewer is <br /> Installation will serve: Residence X Commercial_ Other available within 200 feet) <br /> Number of living units: _Z_ NumbAbrms <br /> Character of soil to a depth of 3 feet:, Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> PK& TREATMENT PLf. ❑ '~. _ Y f / 1 Method of Disposal <br /> Distance to nearest: Well}Foundation - Property Line <br /> / <br /> LEACHING LINE V No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Weiltel 14 <br /> Foundation_/Z_:_ property Line <br /> SEEPAGE PITS Depth Size Number <br /> SUMPS Ll Distance to nearest: Well-X16'4- Foundation 1� Property Line . �5 <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 regulatioris 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-" 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 applicant rn st II for all re uire ins tions. Complete drawing on reverse id . <br /> Signed X Date: <br /> Title: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepte Date I r Area <br /> /Pyf or Grout Inspection b� ate Final Inspection by��� wli n• �( <br /> t/ Date <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 /> FEE AMOUNT DUE AMOUNT REMITTED CK 44 <br /> INFO CASH RECEIVED BY DATE PERMIT'NO. <br /> +.EH 14-261AEV.rin51 gyp, - g ��. -Tk--1919.5 <br />