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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA 0 <br /> - Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 0 \� <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. 1.862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. ; <br /> wk&Job Address Cityt Size PM f. <br /> Owner's N a <br /> ddress Phone r <br /> Contractor Address License Na. Phone <br /> TYPE OF WELL/PU P: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION El <br /> REPAIR El OTHER ❑ y <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 Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> 3 <br /> 11 Public ❑ Other LJT 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 N <br /> Well Destruction ❑ Well Diameter Sealing-Material (top+60'i-1 """���--`- f <br /> Depth 0 Filler Matetal (Below,50') ; <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DI STRUCTION INo septic system permitted if public sewer is <br /> ,,ti!.. <br /> ailable within 200 feet.} <br /> Installation will serve: Residence_ Commercial Other -- <br /> Number of living units: Number of bedrooms <br /> -. Character of sail to a depth of 3 feet: � Water table depth <br /> SEPTIC TANK EJType/Mfg Capacity— <br /> PKG. <br /> apa city No. Compartments <br /> PKG. TREATMENT PLT. 15Method of Disposal <br /> Distance to nearest: Well Foundation <br /> - r <br /> y <br /> LEACHING LINE ❑ No. & Length of lines ' Total length/size <br /> FILTER BED ❑ Distance to nearest: . Well Foundation Property Line <br /> r4 <br /> SEEPAGE PITS' © Depth _ Size L Number <br /> SUMPS 1) 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 <br /> n Joaquin county ordinances, state laws, and <br /> F, <br /> rules and regulations of the San Joaquin Local Health District. i <\, <br /> f 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 /> I employ any person in such manner as to become subject to workman's compensation laws of California."Ccintracr:s hiring or sub-contracting s��natur <br /> toe . <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject tb workman's co n ena- <br /> tion laws of California." 1. <br /> - .. .. 3 <br /> The applicant mus all for all requ- ins1�cti s.+C plate wing on rev rse side. <br /> Si ned Title: Date <br /> c <br /> R'DE7 A TMENT USE ONLY''"°"" <br /> i �{ ' VI^ Y� . �1—a.�nr�4.nnl� Date 3 1'�"J Area:'`' <br /> Application Accepted by - <d <br /> Pit or Grout Inspection by Date Final Inspection by <br /> Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> F Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk,, CA 95201 <br /> ' 4 <br /> FEE AMOUNT DUE AMOUNT REMITTED C RECEIVED BY DATE PERMIT'N0. <br /> INFO �^ C H <br /> + EH 1324[REV. /e51 3 71, �� ��4 `874A <br /> LI <br /> EH 14-26 <br />