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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone'(209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE.ISSUED <br /> (Complete in Triplicate); <br /> I 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 /> 3 'I . '`� `arc/• Q,� Q,cd� <br /> Job Address - City Lot Si PM.' <br /> Owner's Name Address Pone <br /> i Contract .Address License No. Phone_ <br /> l <br /> TYPE OF WELClPUMP: ` NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> f <br /> ;-!Zu 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 3 <br /> R <br /> ❑ Domestil c/Private ❑ Gravel Pack [D Tracy Type of Casing Specifications <br /> ❑ Public } ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ IrrigatioA ---Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction O Well Diameter Sealing Material (top 50') <br /> I Depth Filler M {Belo 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR! DITIO DESTRUCTION ❑ Wo septic system permitted if public sewer is <br /> / available within 200 feet.) <br /> I Installati�n will serve: Residence v Commercial_ Other a e <br /> Number of living uits: Numbe f edrooms v <br /> Character of soil to;a depth of 3 feet:. Water table depth Q <br /> reg <br /> SEPTIC TANK � [IType/Mfg 'Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ _ Method of Dispose! <br /> S Distance to nearest: Well Foundation Property Line <br /> length/size— <br /> FILTER <br /> en th e a <br /> LEACHING LUTotal /sizeNE No. & Length of lines °L g <br /> FILTER BED ❑ Distance to nearest: Well _. Foundation--/, Property Line S ._.." <br /> SEEPAGE PITS" f ' Depth Size i tk Number .. �- <br /> SUMPS ,- ❑ Distance to nearest: Well` J �_.l Foundation Property Line <br /> DISPOSAL PONDS i ❑ <br /> I hereby certify that I'have prepared this application and that'thework will-be done in accordance with San Joaquin co un.ty(ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner oi'licensed agent's signature certifies the following: "I certify that int the performance of the work for which this permit is issued, l shall not <br /> I employ any,pe�son in such manner as to become subject to workman's compensation-laws of California."Contractors hiring o(-sub-contractingsignature <br /> certifies the',foll8wing:"'I certify that in the performance of the work for which this permit is issued, I shall employ persons subjec't•to workman's compensa- <br /> tion laws of-California." . . I <br /> The applicant t tali for all re iced i spections. Complete drawing on reverse i <br /> t - '` .:l:, Date: .� , <br /> Signed X — Title: <br /> %4 <br /> Azz� <br /> FORDEPARTMENT USE-0NLYApplication Acceptedrby• i ;"Date <br /> �1J/q— Area <br /> I <br /> Pit or Grout inspection by Dat Final-Inspection-by Dat <br /> i <br /> Additional Comments: <br /> EJ Stk 466-6781 I ❑ Lodi 369-3621 ❑ Manteca 823 7104. ❑ Tracy 635-6385 ' <br /> Applicant - Return all copies to: Environmental Health Permitl,Services;1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201. <br /> -f <br /> FEE AMOUNT DUE AMOUNT REMITTED CASH BYL DATE PERMIT N0. <br /> INFO CASH <br /> r y <br /> t EH 13-20(REV.1/8 51 <br /> w <br /> fH 14-28 <br />