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APPLICATIONFOR PERMIT <br /> ' SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephohe (209) 466-6781 <br /> PERMIT EXPIRES 1YEAR 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 /> n <br /> Job Address City Lot Size PM <br /> 01 <br /> Owner's Name ss - 177. Phone <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ 1 OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPO PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHERWELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom © eca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> (`l Public ❑ Ot ❑ Delta Depth of Grout Seal Type of Grout <br /> I I IrrigationApprox. Depth l l Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ElWell Diameterr __ Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION Ia REPAIR/ADDITION I t DESTRUCTIO INo septic system permitted if public sewer is 1 <br /> yt t available within 200 feet.) <br /> ti <br /> Installation will serve: Residence Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of sail 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 I 1 Depth Size Number <br /> SUMPS ❑ Distance;to nearest: Well . Foundation Property Line <br /> DISPOSAL PONDS ❑ I <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 i , <br /> rules and regulations of the San Joaquin Local Health Di1lrict. <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, 1 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." r <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X° Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by r, Date <br /> Pit or Grout Inspection by t� -Date Fina Inspection by Date �A—afol ~, <br /> Additional Comments: / k <br /> ❑ Stk 466-6781 © Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6395 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE { AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> +..EH13-241RE'V.Iin5) -2 ��• V� lV'{. °� r`^!�V �5(Qb <br /> EH t4-26 <br />