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l . . <br /> r APPLICATION FOR PERMIT <br /> i; SAN JOAQUIN LOCAL HEALTH DISTRICT ll � ��jj��' <br />' 1601 E. HAZEL T ON AVE., STOCKTON, CA !�`"I'' '"�� <br /> i� Telephone (209) 466-6781 <br /> �1 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED /V, <br /> WAG' <br /> i. Ill <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 7 <br /> City I � 4 of Size ply <br /> Owner's Nam <br /> Phone <br /> 1V <br /> Contractor l Address <br /> License No.�_Phone <br /> TYPE OF.WELL/PUMP:_ ,. _q,,.— .,.NEW WELL p,,, WELL-REPLACEMENT ❑ r _DESTRUCTION ❑ <br /> ,PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑~ �� CA <br /> DISTANCE,TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. t PROP. LINE �A <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Vl <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial p Open Bottom ❑ Manteca Dia. of Well Excavation r Dia. of Well Casing <br /> LJ Domestic/Private O Gravel Pack ❑ Tracy Type of Casing Specifications <br /> I'l'Public ❑ Oiher ❑ Delta Depth of Grout Seal <br /> Irrigation �� Type of Groui <br /> I I Irri <br /> g" 1 Approx. Depth { I Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type,of Pump H.P. i State Work Done{_ <br /> Well Destruction ❑ Welf(Diameter Sealing Material [top 501 t <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW IN-STALLAT ON I 1 REPAIR/ADDITION l I DESTRUCTIO [No septic system permitted if public sewer is <br /> �( available within 200 feet.) <br /> Installation will serve: Residence 4Z 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 , <br /> /Mfg � <br /> Capacity No. Compartments <br /> PKG. TREATMENT PLT. O' <br /> Method of Disposal <br /> Distance to nearest: Well FoundationProperty Line <br /> it , <br /> - f <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation' Property Line <br /> } 1 <br /> SEEPAGE PITS 11 Depth _Size � Nbmber <br /> SUMPS Cl Distance to nearest: Well��� Foundation. Property Line <br /> DISPOSAL PONDS ❑ !I• 1� ; _rA <br /> H <br /> I hereby certify that I have prepared this application and=dhat,the work will be done in acco'rdance,with`-San Joaquin count ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. " ti' t q y J <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 III <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, l shall employ persons subject to workman's compensa- <br /> tion " <br /> tion laws of California." t { 3 <br /> The applicant must call fora 1 required fnspections:–Complete-drawing-on'reverse'siije. II <br /> Signed X Title Date: <br /> 3 I!' <br /> Fr IDEPARTMENT U5E ONLY <br /> r � <br /> Application Accepted by; I Date Area �� <br /> ata <br /> i r <br /> Pit or Grout Inspection by i I� Final Inspection by <br /> Date <br /> Additional Comments: �l 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 T AMOUNT DUET .�AMOUNT;AEM'ITTE��` ' �.n ­DATE— <br /> .. _ ,�._ ,INFO,. x_ CASH'. 'i,1 RECEIVES BY "'PERMIT'NO"^ �- t <br /> a EH 13-24 rREV.t i H sl <br /> EH 14-26 i � pnf <br /> ip <br />