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s <br /> APPLICATION FOR PERMIT L <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE"TON AVE., STOCKTON, CA �O <br /> Telephone 12091 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. i <br /> 5 G.rG t <br /> Job Address `� � � City � Loi Size PM <br /> �f Owner's Name Address ph 4 7 <br /> 11\\ Contractor AddressR <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> iI <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS i <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 F ❑ 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'rY \ <br /> Well Destruction ❑ Well Diameter Sealing Material Itop 50') <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 /> 11vailable within 200 feet.) <br /> Installation will serve: Residence i Commercial— Other c <br /> Number of living units: Number of bedrooms t <br /> Character of soil to a depth of 3 feet: i 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 /> LEACHING LINE ❑ No. & Lengt1h of lines Total length/size <br /> FILTER BED ❑ Distance toinearest: Well Foundation Property Line 'a. . <br /> I <br /> SEEPAGE PITS ❑ Depth ( Size Number l <br /> -, <br /> SUMPS ❑ Distance to&nearesi: Well Foundation t Property Line h <br /> DISPOSAL PONDS ❑ J r <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 f <br /> rules and regulations of the San Joaquin!Local Health District. <br /> Home owner or licensed agent's signature jcertifies 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 t <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." l <br /> The applicant m II for.all required inspections. Complete drawing on reverse side. ^, <br /> Signed Title: '/Date: d t <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by bate Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> 3 s <br /> ❑ Stk 466-6781 ❑ Lodi 369-36211 ❑ Manteca 823-7104 ❑ Tracy 835-6386 I <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 REMITTED CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 13-24(REV.1/8 5) <br /> EH 14-28 � �� •7 <br />