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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL'HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA 4 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 1 <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 /> p made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Ryles and Regulations of the San Joaquin <br /> `I Local Health District. <br /> Job Address ,� <br /> s . . City <br /> Lot Size QPM` <br /> Owner's Name Address <br /> `,� Phone <br /> Contractor Address /� <br /> TYPE OF WELL/PUMP: License No. Phon <br /> I NEW,WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ <br /> DISTANCE 70 NEAREST: SEPTIC TANK OTHER ❑ <br /> SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL <br /> INTENDED USE PITS/SUMPS <br /> TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industria! ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> ❑ Domestic/Private ❑ Gravel Pack D Tracy T Dia. of Well Casing <br /> Type of Casing Specifications <br /> ❑ Public <br /> Cl Other ❑ Delta Depth of Grout Seal <br /> ❑ Irrigation --- of Grout <br /> _—Approx. Depth E3 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. <br /> State Work Done <br /> Well Destruction ❑ Well Diameter <br /> Sealing Material (top 50'1 <br /> l <br /> Depth ; Filler Material (Below 501 <br /> TYPE Of SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITION DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> Installation will serve: Residence X, Commercial` Other available within 200 feet.) <br /> Number of living units:0-> Number of bedrooms <br /> Character of soil to a depth of 3 feet: <br /> Ze <br /> SEPTIC TANK ) Type/Mfg - Water table depth <br /> (rapacity Znn-f1jE It <br /> PKG. TREATMENT PLT. F-1 - L- No. Compartments <br /> Method of Disposal <br /> Distance to nearest: Well Lk%2Foundation Property Line .� d <br /> LEACHING LINE No. & Length of lines- <br /> FILTER BED Total length/size <br /> kb <br /> SEEPAGE PITS ❑ Depth Size <br /> SUMPS �'�-` ler <br /> Distance to nearest: Well Foundation Property Line_-�_ g♦ <br /> DISPOSAL PONDS ❑ <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 /> 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 call fob all requir i pe ions. Comple drawing on reverse side. <br /> Signed <br /> itle: bate:gam` <br /> FOR DEPARTMENT USE ONLY l <br /> Application Accepted by t Date zAr�� <br /> Area <br /> Pit or Grout Inspection by Datepd 9 <br /> Final Inspection by Date r� D <br /> Additional Comments: <br /> ❑ Stk466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1801 E. Hazelton Ave.,'P.O. Box 2009, Stk., CA 95201 <br /> IFEE <br /> NFO AMOUNT DUEAMOUNT REMITTED CK# <br /> CASH RECEIVED 8Y DATE PERMIT`NO. <br /> + EH 1344IREV.1/85) 1�D <br /> EH 10.26:, <br />