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APPLICATION.FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> r 1601 E. HAZEL T ON AVE.,iSTOCKTON, CA r` <br /> l 'Telephone {209Y 466-6781 <br /> ' PERMIT EXPIRES`? YEAR FROM DATE ISSUED <br /> I: <br /> 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 /> Job Address �Q 1.yl, tV r,G <br /> City a Lot Size PM i <br /> .F e ` <br /> Owner's Name Address i <br /> ,�. Phone <br /> .� I . <br /> tractor i Address <br /> License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ `� WELL REPLACEMENT ❑ ESTRUCTI <br /> ON ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES ; a DISPOSAL FLO ,a PROP. LINE <br /> FOUNDATION l AGRICULTUR LL - -OTHER WELL- - PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial Cl Open Bottom ❑ M ca Dia. of Well Excavation ` <br /> Dia. of Well Casing <br /> El Domestic/Private C1 Gravel Pack Tracy Type of Casing t Specifications <br /> L7 Public ❑ er ❑ Delta <br /> Othdepth of Grout Seal <br /> ❑ Irrigation t Type of Grout <br /> 9 ;A x. Depth ❑ Eastern Surface Seal Installed by f <br /> Repair Work Done ❑ e of Pump <br /> H.P. State Work Done <br /> Well Destruction Well Diameter <br /> Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO <br /> r (No septic system permitted if public sewer is `� I <br /> available within 200 feet.} <br /> installation will serve: Residence Commercial, Other <br /> Number of living units: 'I Number of bedrooms . . <br /> Character of soil to a_depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg f' <br /> Capacity No. Compartments I <br /> PKG. TREATMENT PLT. ❑ � a <br /> Method of Disposal (1 <br /> Distance to nearest: Well Foundation r Property Line ` <br /> LEACHING LINE ❑ No. &'Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1Y Depth T q Size <br /> Number <br /> SUMPS . ❑ .Distance to nearest: Well Foundation <br /> p rty'Line" <br /> DISPOSAL PONDS ❑ ISI <br /> I hereby certify that i have prepalied this application and that the work will be done in accordance with San Joaquin county ordinances, state l <br /> rules and regulations of the San Joaquin Local Health District. aws, and <br /> 1 <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 IL <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 for all�. <br /> reqiwired inspections. Complete drawing on R <br /> reverse side. <br /> Signed X Title: Date. <br /> FOR DEPARTMENT USE ONLY j <br /> Application Accepted by Date Z _ p <br /> Area <br /> Pit or Grout Inspection H Date Final Inspection by Date 1J C> 1 ! <br /> f� l C C1 ' <br /> ' Additional Comments: G✓�,. ' <br /> El Stk 466-6781 71 Lodi 369-3621 13 Manteca 823-7104 ❑ Tracy 835 6385 <br /> Applicant - Return all copies to: Elnvironmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> i <br /> FEE <br /> INFO AMOUNT'DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. } <br /> + EH13-24 IRev,I/a 51 <br /> EH 14-ZB <br />