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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) 4666781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> m le#e in Triplicate) <br /> �Wth, <br /> 1C� ' p ) <br /> Application is hereby 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\ r/'` ddress 2, 0 .one / <br /> Contractor Address: "' License No. Phone <br /> TYPE OF WELL/PUM : NEW WELL ❑ i WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> P N! TALLATION ❑ SYSTEM REPAIR 1:1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TA SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION RICULTURE WELL OTHER WELL S/SUMPS <br /> INTENDED,USE TYPE OF WELL PROBLEM AREA ECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca a. of Well Ex Dia. of Well Casing <br /> k, <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications <br /> ❑ Public ❑ Other Delta Depth of Grout Seal Typ rout `\ <br /> ❑ Irrigation �-.._4ppr . epth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ T of Pump H.P. State Work Done <br /> Well Destruction Well Diameter Sealing Material ftop 50') <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION lNo septic system permitted if public sewer is <br /> vailable within 200 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: 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. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ 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 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 must call for all required i spections. Complete drawing on reverse side. <br /> Signed �^` Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date Area O <br /> Pit or Grout Inspection Date ,Fi1 I Inspection b / Date <br /> Additional Comment <br /> ❑ Stk 466-Ml ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835.6385 It / <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 7009, Stk., CA 95201 9 <br /> FEE 1 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> tEHM241REV.1/0sl ` oy <br /> EH 14-28 <br />