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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT T,� b %,J <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> I� Telephone (209) 466-6781 <br /> i, PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> i� (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, n <br /> Job Address/�/c�'�7�["1^��� 1,C Lot Size PM } <br /> '1 x_ a <br /> Owner's Na I; Address !S;0q—A Phone <br /> Contractor sd%iP Address Y License No. Phone } <br /> TYPE OF WELL/PUMP: ,i NEW WELL❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK WER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AG ULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM ARE CONSTRU ION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom 171 Manteca ia. of W II Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Typ f asing Specifications <br /> F] Public ❑ Other D Delta Depth rout Seal Type of Grout O <br /> I i Irrigation —'.Approx. Depth I I Eastern Surf ce Seal Iled by <br /> Repair Work Done D Type of Pump H.P. State Work Done pQ <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 i <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION [1 REPAIR/ADDITION l 1 DESTRUCTIONX INo septic system permitted if public sewer is -y <br /> II available within 200 feet.M ! <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number 0f living units: II Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity "No:Compartments <br /> PKG. TREATMENT PLT. ❑ �� Method of Disposal" <br /> 9 <br /> Distance to nearest: Well Foundation Property Line t <br /> LEACHING LINE ❑ No. & Length of lines Total lengthlsize r <br /> FILTER BED ❑ Distance to nearest: Well Foundation I Property Line , <br /> SEEPAGE PITS I I Depth Size Number l <br /> SUMPS LI 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 i <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: ' ertify,that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's campensa <br /> tion laws of Ca"for <br /> The applicant t c for all req 'r n o plate drawing on reverse side. ° 7 <br /> Signed X Title: Date: <br /> I' RMENT USE ONLY <br /> Application Accepted by Date (1" t L.-P Area <br /> Pit or Grout Inspection by Date Final Inspection by r Date <br /> Additional Comments: J <br /> C1Stk 466-6781 ❑Lodi 369 3621 ❑ Maniacs 823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Boz 2 , Stk., CA 85201 <br /> i <br /> FEE AMOUNT DUE AMOUNT REMITTED K H RECEIVED BY DATE PERMIT*NO. <br /> INFO <br /> + EH EH 14.24(REV.I/H 5)26 <br /> L21 <br /> r <br /> I <br />