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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 i <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 welllpump and the Rules and Regulations of the San Joaquin <br /> al Health District: t <br /> City Lot Size PM <br /> F <br /> Address <br /> ner's Name Address �;s2�� � ^ Phone <br /> l <br /> Contractor <br /> Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL 17WELL REPLACEMENT ElDESTRUCTION ❑ <br /> PUMP INSTALLATION '❑ SYSTEM REPAIR ❑ OTHER Cl <br /> DISTANCE TO NEAR <br /> SEWER LINES DISPOSAL FL PROP. LINE <br /> FOUNDATION URE WELL WELL PITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO ECIFICATIONS W <br /> ❑ Industrial <br /> ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> 171 Domestic/ <br /> Domestic/Private ❑ Gravel Pack acy Type of Casing p <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type rout <br /> Cl Irrigation prox. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done Type of Pump H.P. State Work Done <br /> Well Destruc n LJWell Diameter Sealing Material (top 501 <br /> Depth Filler Material IBeiow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION❑ REPAIR/ADDITION ❑ DESTRUCTIO) aNailseptic <br /> able cystithin m permitted if public sewer is <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 /> r SEPTIC TANK LJ Type lMfg Capacity_ No. Compartments <br /> ar Method of Disposal <br /> . TMENT PLT. ❑ <br /> PKCT& <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> f SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> t <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 fawn, an <br /> + <br /> rules and regulations of the San Joaquin Local Health District. <br /> ormance of the work for which this permit is issued, 1 shall not <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the perf <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,1 shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant must call for II quired inspections. Complete drawing on reverse side. <br /> { � � Title: Date: z <br /> 1 Signed <br /> FOR DEPARTMENT USE ONLY Q <br /> Date "~ Area <br /> Application Accepted by �.Gf <br /> Pit or Grout Inspection by <br /> t Date final Inspection by Dace <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 li❑ Manteca 823-7104 ❑ Tracy 835-6365 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazekon Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT"NO. <br /> i INFO <br /> + EH 13-24(REV. <br /> EH 14.26 <br />