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i <br /> Y 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 YYEAR 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 City Lot Size PM <br /> Owner's Name i Address �') Phone <br /> Contractor s6_1Address 44 License No.2�y�/6D Phone <br /> TYPE OF WELL/PUMP:,.. NEW WELL,C1 WELL REPLACEMENT ❑ DESTRUCTION O <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> M _ 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 �­ s❑ Tracy Type of Casing — Specifications Vol <br /> fl Public F Other n Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation -Approx. Depth l 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 505 <br /> Depth Filler Material IBelow 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION i-I DESTRUCTION I (No septic system permitted it public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial Other <br /> Number of living units: Number of bedrooms <br /> TM Character of soil to a depth of 3 feet:. 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 /> } I <br /> LEACHING LINE LI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r <br /> d <br /> SEEPAGE PITS ['I Depth Size _ Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <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 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 I ch manner as to become subject to workman's compensation laws of California.•• Contractor's hiring or sub contracting signature <br /> certifies the follow: g: erti Ahat 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 Calif r1i <br /> The applicant mu equired inspections. Complete drawing on reverse side. _ <br /> Signed X 'i� Titre: � Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area ' <br /> Pit or Grout Inspec' yDate Final Inspection by Date y <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 ' <br /> INFO AMOUNT DUE AMOUNT REMITTED C///A��SSH RECEIVED BY DATE ry����{ FPERMIT'NO. <br /> + EH 13-24(RE'V.1/H 5) �%/ ��, � / <br /> EH 14-2$ W ! VVV <br />