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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) 466-6781 <br /> PERMIT EXPIRES 7 YEAR FROM DATE ISSUED <br /> i (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 /> _L41 <br /> Job Address City Lot Size <br /> PM <br /> Owner's Name Address <br /> Phone <br /> Contractorddress ense No. Phone 0 <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION El <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 VV <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 ID 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 V <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if publicsewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units:--J— Number of bedroomI/ <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg . Capacity�,Pd No. Compartments <br /> PKa G. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well FoundatianZa <br /> Property Line <br /> i <br /> LEACHING LINE No. & Length of lines Total length/size d . <br /> FILTER BED ❑ Distance to nearest: Well ��Foundation Gar Property Line <br /> SEEPAGE PITS ❑ Depth X J Size Number 13 <br /> l ❑ Distance to nearest: Well Foundation h, Q _ Property Line <br /> SPOSAL 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 inspectio s. Complete drawing on rem side. <br /> Sigij ned Title: IOY Date: ' <br /> FO DEPARTMENT USE ONLY <br /> Application Accepted by 4 ✓' `.� l <br /> Date Area <br /> Pit rout inspection by Date Final Inspection by <br /> A .itional Co ants: <br /> ❑ Stk 466 6781 ❑ Lodi 369-3611 ❑ Manteca 823 7104 ❑ Tracy 835�iB5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95MI <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT NO. <br /> INFO CASH <br /> a EH 13-24(REV.x/95) <br /> EH 14-28 / • 60 -laS <br />