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L. 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 /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in��Ithwmk er ndescribed.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 Address Phon <br /> �O: � <br /> 7 }. �� � <br /> Contract Addre �J .G License ��3'l D Phon <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WEL <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRU ECIFICATIONS <br /> © Industrial ❑ Open Bottom ❑ Manteca - of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tr Type of Casing Specifications <br /> I"1 Public ❑ Other Delta Depth of Grout Seal Type of Grout <br /> I I Irrigation / A X. Depth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ pe of Pump H.P. State Work Done <br /> Well Destructio ❑ Well Diameter Sealing Material Stop 5€1'1 <br /> Depth Filler Material (Below 50') <br /> T PE OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTIO No septic system permitted if public sewer is <br /> -available 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 CI No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS Ll 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 applica ust call for all required inspections. Complete drawing on r e�rse side <br /> Signed - Title: ✓ Date: <br /> FOR DEPARTMENT USE ONLY { <br /> Application Accepted b <.9 1 <br /> pP p y Date � Area 'Q <br /> Pit or Grout Inspection by Date Final Inspection by DateNf <br /> S 2 f+ <br /> Additional Comments: Q / <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ 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 INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED 13Y DATE PERMIT' <br /> 'NO. <br /> + EH 14-24(REV.I/x 51 .J tem.c �� C43 <br /> EH 14-29 J <br />