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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> 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 well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ( <br /> Job Address City Lot Size D vzpm <br /> Owner's Name Address <br /> l Phone ¢ / <br /> Contractor's Name g ��—'� �L4icense No. 1 Phone oto o� <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LiNE <br /> FOUNDATION .AGRICULTURE WELL .OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Weli Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAID/ADDITION ❑ DESTRUCTION Q Mo septic system permitted if public sewer is <br /> I available within 200 feet.) <br /> Installation will serve: Residence_ Commercial her <br /> Number of living units: Number of bedrooms_ 'k <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK Ui,-�ype/Mfg Capacity—JIQQO No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: ell Foundation �� Property Line ,_` <br /> LEACHING LINE CL,Ko. & Length of lines Total length/size 1 d <br /> FILTER BED ❑ Distance to nearest: Well Foundation - _ Property Line <br /> SEEPAGE PITS @Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation z Property Line S — <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 parsons subject to workman's compensa- <br /> tion la of California." <br /> The applican <br /> us call for all quire 'nspJinC let drawing o reverse s' a. f <br /> Signed Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted byWdate � � Area�� <br /> Pit or Grout Inspection by Date �� Final Inspection by Date 0 <br /> Additional Comments: <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 AMOUNT DUEAMOUNT REMITTED RECEIVED BY <br /> INFO `` CK DATE PERMIT'No. <br /> + EH 1324 IREV.19/affi A"i 5 19 <br /> EH 1426 / lt <br />