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i.: .. <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> a <br /> • 1601 E. HAZELTQN AVE., STOCKTON, CA <br /> ir Telephone (209) 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 weil/pump and the Rules and RegulYatio of the San Joaquin <br /> L <br /> ocal Health District. <br /> City Lot Size PM <br /> JOb Address yp� <br /> Owner's Name <br /> i Address Phone(IV <br /> contractor ss <br /> �^ erase No. Phone <br /> -1TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> I <br /> DISPOSAL FLD. PROP. LINE <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> { <br /> I� <br /> FOUNDATION AGRICULTURE WELL <br /> OTHER WELLPITSISUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS - ,L <br /> Dia. of Well Casing <br /> I Industrial ❑ Open Bottom lk <br /> Manteca Dia. of Well Ex <br /> e of Casing cavation O <br /> 4 F Specifications <br /> Li Domestic I Private ❑ Gravel Pack d Tracy TypType of Grout <br /> e Public ll Other Cl Delta Depth of Grout Seal !"R <br /> t I Irrigation -qw-Approx. Depth I I Eastern Surface Seal Installed by <br /> F H p State Work Done <br /> Repair Work Done L:) Type of Pump <br /> I Well Destruction ❑ Well Diameter Sealing Material Itop 50') — <br /> 1 Depth Filler Material (Below 50'I <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION t 1 REPAIR/ADDITION I.I DESTRUCTION I I (No septtavarlable wit hin 200 feetc stem .) if public sewer is <br /> Ij Installation will serve: Residence— Commercial— Other <br /> Number of living units: Number of bedrooms <br /> I Water table depth <br /> Character of soil to a depth of 3 feet: <br /> I Capaci[ No. Compartments <br /> SEPTIC TANK O Type/Mfg Y ! <br /> �PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ ,No. & Length of lines Total length/size <br /> IIFILTER BED ❑ 'Distance to nearest: Well Foundation Property Line <br /> i Number <br /> SEEPAGE PITS f I Depth Size — <br /> ` SUMPS D Distance to nearest: _Well Foundation_ Property Line - <br /> DISPOSAL PONDS �❑ <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 work for which this permit is issued, I shall not <br /> 1 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, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applic u all or all uired inspections. Complete drawing on r erse side. .�----_ <br /> 27 <br /> Signed <br /> Title, Date: <br /> I rA <br /> FOR DEPARTMENT USE LY <br /> I Date' Area <br /> . Application Accepted by <br /> Date Final Inspection by Date <br /> Pit or Grout Inspection by a <br /> Additional Comments: r -Z <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 anteca -7104 ❑ Tracy 83 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> .• FEERECEIVED BY DATE AMOUNT DUE AMOUNT REMITTED CASH PERMIT ND. <br /> !NFO <br /> + EH 1324 lH EV.I/H5) <br /> EH 14-2t1 <br />