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�s <br /> APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 0,,� ,ar <br /> Telephone {209) 466-6781 ,x, <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED)P:: <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 /> 9a <br /> Job Address �r- /V City -5-rac /1 <br /> of Size 11.5 +!3 PM <br /> Owner's Name W 't? D N AddressPhone <br /> i � Z 4 <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> 1 11 PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANSEWEtCR LINES DISPOSAL FLD. LINE <br /> FOUNDATION ULTURE WELL OTHER PITS/SUMPS _ <br /> INTENDED USE TYPE OF WELL PROBLEM AREACONS PECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Type of Casing ecifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type o ut <br /> ❑ Irrigation x. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ ype of Pump H.P. State Work Done <br /> Well Destructio ❑ Well Diameter Sealing Material (top 50') <br /> Depth Filler Material 18elow 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is r <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 X Type/Mfg q9 Capacity No. Compartments <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 /> A. <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ 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 /> 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 applicant must pall for al a fired ictions- Complete drawing on reverse side. <br /> Signed Title: Date: f� <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date tel' Area <br /> Pit or Grout Inspectio b Date / Final Inspection by _i e,1(L. _S6M5 �^1_ Date <br /> Additional Comments: .s <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 DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMIT'NO. <br /> + EH 13-24(REV. �� Q ` <br /> EH 1446 D q 7 <br />