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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> tt, ti <br /> -1601 E. HAZE T ON AVE.', STOCKTON, CA <br /> Telephone 1209) 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 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 CityLot Size PM <br /> Owner's-Name r <br /> Address. ' Phone_ <br /> {S' <br /> Contractor's Name ©®17 License No. ����� � Phone <br /> TYPE OF WELL/PUMP: a NEW WELL ❑ WELL-REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST; SEPTIC TANK I SEWER LINES i DISPOSAL FLD. PROP. LINE <br /> I FOUNDATION AGRICULTURE WELL,— OTHER WELL PITS/SUMPS i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA j_CONSTRUCTION SPECIFICATIONS 3 <br /> ❑ Industrial '❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing I <br /> ❑ Domestic/Private ❑ Gravel Pack- ❑ Tracy N Type of Casing Specifications <br /> El Public L1 Other _ r .El Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation , _-Approx. Depth ❑ Eastern Surface Seal Installed by 3 ti I <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done i <br /> Well Destruction ❑ Well Diameter-' Sealing Material [top 50`1 <br /> Depth Filler Material (Belo 50') <br /> TYPE.OF SEPTIC WORK: NEW INSTALLATION_ ElREPAIR/ADDITION DESTRUCTION ElINo septic-system permitted if public sewer is <br /> N1- available within 200 feet.) I <br /> Installation will serve: Residence— Commercial-Z Other Sy <br /> Number of living units: Number of bedrooms .--� <br /> Character of sail to a depth�f 3 feet: �� « Water table depth Z4 � - <br /> .. <br /> SEPTIC TANK l�' Type/Mfg tee — PSL. Capacity L'Lc�3Cl No. Compartments 2- <br /> PKG. <br /> PKG. TREATMENT PLT. ❑ J Method of Disposal <br /> Distance to nearest: Well Foundation /d Property Line .. <br /> LEACHING LINE No. & Length of lines f' 70 d Total length/size <br /> 0' <br /> FILTER BED ❑ Distance to nearest:'--Well Foundation Property-tine <br /> SEEPAGE PITS ❑ Depth Size Number I I f <br /> SUMPS ❑ Distance-to-nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ } 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 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 w 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." I I I ' � ' <br /> The applicant must call for all required inspectio Complete drawing on reverse side. f <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted bye Date Area <br /> '— <br /> I <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: _ -- -- ---- - - i <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 <br /> INFO AMOUNT f7UE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT­NO. <br /> 1Y <br /> + EH 14-26(REV.10183) 3/ g i'{ <br />