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' APPLICATIONFOR PERMIT <br /> } SAN JOAQUIN LOCAL'HEALTH DISTRICT ` A <br /> 1601 E. HAZE i ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 ^- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED ( <br /> * (Complete in Triplicate) V <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 /> a Local Health District, <br /> Job Address City Lot Size PM <br /> Owner's Nam Address 7 <br /> Phone k6 VIV 00127 <br /> 4 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUW. 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 PR08LEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing _ <br /> ❑ Domestic/Private C] 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 (top 50') <br /> Depth Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO No septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence! Commercial_ i Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:" m Water table depth <br /> SEPTIC TANK Type/Mfg Capacity No. Compartments <br /> f PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distances nearest: Well Foundation Property Line <br /> j I <br /> SEEPAGE PITS ❑ Depth Size Number } <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ n <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 I <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." 1 <br /> The applicant must call for all required inspections."Complete drawing on reverse side. <br /> tl <br /> J _ Signed Title: Z - Date: lC� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date `• o- 9 3 ! <br /> Area <br /> Pit or Grout Inspection Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 4666781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 i <br /> Applicant- Return all copies to: Environmental Health Permit/Servioes 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> INFO AMOUNT DUE t' AMOUNT REMITTED C5H RECEIVED BY DATE PERMIT`NO. <br /> y <br /> IEH 3-24 <br /> + EH 1426(REV.1/85) D �y A ' <br />