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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> w (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 r City at Size PM <br /> Owner's Name Address Phone — %5 <br /> Contractor_ { Address License No. Phone <br /> TYPE OF WELL./PUMP:, NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 'PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISP FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL THER WELL PITS/SUMPS I <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CO UCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel P�Depth <br /> ❑ y Type of.Casing_ Specifications •� <br /> f l Public ❑ Other ❑ pelta Depth of Grout Seal Type of Grout _. w <br /> I I Irrigation -App i I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ T ~� <br /> p Type of Pump._ H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 50') r_ <br /> Depth Filler Material (Below 50 v� <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION I ) DESTRUCTION I {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. ❑ I Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 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 LI . Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS El <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 /> y 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." Contractors 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." t <br /> The applicant m call for all required inspections. Complete drawing on reverse side. q�r <br /> Signed X Title: Date: ;r-- <br /> FOR <br /> r~FOR DEPARTMENT USE ONLY <br /> fc <br /> Application Accepted by Date ~ Area `� <br /> Pit or Grout Inspection by Date Final Inspection b Date <br /> Additional Comments: Ct <br /> Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca -7104 ❑ Tracy 835-W!? <br /> r pplicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazalton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED 8Y DATE PERMIT'NO. <br /> ♦ EH t3-24(REV.r/e 5) <br /> EH 14-28 <br />