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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 1 YEAR FROM DATE ISSUED I <br /> Ir i <br /> (Complete in Triplicate) I <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 f <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 1 <br /> j Owner's Name .,If:— _ Address Phone <br /> Contractor gr�Address License Phone_ <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT, ❑ DESTRUCTION ❑ <br /> P4UMP,INSTALLATION -.SYSTEM REPAIR__C] -_ _ OTHER 0­ <br /> DISTANCE TO NEAREST: SEPTIC TANKSEWER LINES DISPOSAL FLD. PROP. LINE /010s k <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 <br /> 40 Domestic/Private Gravel Pack FJ Tracy Type of Casing F Specifications V1 <br /> .._.,. <br /> 1'1 Public Cl Other �71 Delta Depth of Grout Seal fid Typo of Giout-F <br /> 1 Irrigaeign - pprox, Depth I I Eastern Surface Seal Installed by eVy►ZLi 05r <br /> Repair Work Done ❑ Type of Pump .sCt H,P. `? State Work Done <br /> Well Destruction ❑ Well Diameter 0-"7 <br /> Sealing Material (top 501 I <br /> Depth Filler Material (Below 50'1 <br /> TYf E OF SEPTIC WORK: NEW INSTALLATION I 1 REPAIR/ADDITION I 1 DESTRUCTION I 1 INo septic system permitted if public sewer is <br /> �I available within 200 feet.) j <br /> Installation will serve: Residence_ Commercial—_Other <br /> Number of living units: I Number of bedrooms <br /> Character of soil to a depth of:3 feet: Water table depth <br /> SEPTIC TANK ❑. Type/Mfg capacityNo. Compartments as <br /> PKG. TREATMENT PLT: ❑ �0 Method of Disposal <br /> Distance to nearest: Well Foundation Z. Line <br /> LEACHING LINE ��❑ ..No. & Length of lines /Total length/size <br /> FILTER BED El, Distance to nearest: Well Joundation Property Line <br /> SEEPAGE PITS i I Depth Size r _ Number <br /> SUMPS ❑ Distance to nearest: Well,- Foundation Property Line <br /> DISPOSAL PONDS ❑ L R <br /> 1 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 ofsthe San Joaquin Local,Health Di3trict. I <br /> Home owner or licensedagent's signature certifies-the-following:-"`(-certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person-in sur ,'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." N <br /> The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed -dam Title: J <br /> bate: — <br /> Ii FOR PARTMENT USE ONLY <br /> N <br /> Application Accepted by Date Area y <br /> k <br /> Pit or t Inspection b}r c (Date Final Inspection by ; Date L2 y <br /> Additional Comments: <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 /> n <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT*NO. <br /> a.EH13.241REV.i/nal 3r g <br /> EH t4-2a <br />