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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 <br /> (Complete in Triplicate) r <br /> a' <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 City Lot Size �11� PM <br /> Owner's Name / Address - Phone - <br /> Contractor ddressL cense No. Phone <br /> TYPE OF WELL/PUMP: f 14M ELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION 0 SYSTEM REP ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD..- PROP. LINE <br /> I FOUNDATION GR ULTURE L OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AR ONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia" of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Trac Type of Casing Specifications <br /> El Public E3 Other elta k 1— �- 0,pth`of"Grout SeaIT - �-- Type of Grout <br /> El Irrigation <br /> Irrigation --Approx. . ep ❑ Eastern Surface Seal Installed by g <br /> Repair Work Done ❑ Type of Pump' ti H.P. ' State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 50') <br /> Depth t Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available thin 200 feet.) <br /> Installation will serve: Residence�y 4,Commerciai Other z i . <br /> Number of living units: Number'of bedrooms or <br /> Character of soil to a depth of 3 feet:. %" "" E Water table depth <br /> SEPTIC TANK ❑ Type/Mfg CapacityNo. Compartments F <br /> PKG. TREATMENT PLT. D Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE _El No. & Length of lines Total length/size <br /> FILTER BED Cl Distance to nearest: Well Foundation Property Line r , <br /> SEEPAGE PITS 0 Depth ( Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 1� F <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 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 subjet 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." I `. i <br /> The applicant m call for all require_O inspections. Complete drawing on reverse side. <br /> Signed Title: Date: <br /> ai FOR DEPARTMENT USE ONLY ' <br /> Application Accepted by 'L- Date Ct 1 i Area u <br /> Pit or Grout Inspection by Dat@ inial /Hsps "on byY Date <br /> i <br /> Additional Comments: <br /> El Stk 466-6761 ❑ Lodi 369-3621 El Manteca 823-7104'Lj .O 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 /> INFO AMOUNT DUE . AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT`NO. <br /> 1 FEE <br /> + EH 13-24 CK <br /> (R <br /> r/851 <br /> EH 1 <br /> 428 <br /> i <br />