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T — — r — <br /> APPLICATION FOR PERMIT 5> <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA J <br /> Telephone (209) 466-67$1 <br /> PERMIT EXPIRES 1 YEAR 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 /> Job Address Aa City Lot Size � <br /> n !� PM <br /> Owner's Name Address � <br /> Phone6 <br /> Contractor Address l77A-e ���p� <br /> License Na. Phone <br /> TYPE OF WELL/PUMP: EW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION-0 <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SE INES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU ELL OTHER WELL PITS/SU <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTR ION SPECIFICATIONS / <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Ex va' Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy T asing _ Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth astern Surface Seat Installed by <br /> Repair Work Done ❑ Type of Pum H.P. State k Done <br /> Well Destruction ❑ Well . eter Sealing Material (top 501 111 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ Wo septic syst permitted if public sewer is <br /> available vqtliln 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 i <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation _ Property Line <br /> n' <br /> LEACHING LINE ❑ No. & Length of lines <br /> 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 /> 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 <br /> ' y 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 applican st call fora quired inspections. Complete drawing on reverse side. <br /> Signed Title: <br /> Date: <br /> FOR PA ENT USE ONLY <br /> Application Accepted bye ink minlZbDate — Area <br /> Pit or Grout Inspection b 1 �] <br /> pe Y n Date Final Inspection b Date%._y6 I <br /> Additional Comments: ✓!w <br /> C7 Stk 466-6761 : ❑ Lodi 369-362 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNTCK40 <br /> INFO DUE AMOUNT REMITTED CASH RECEIVED BY GATE PERMIT•NO. <br /> + EH 1 <br /> 3-24 iREV.i i y sY -�{ i__E_: � /�� <br /> EH 14-28 V < <br />