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r f ITJ It�� APPLICATION FOR PERMIT <br /> i <br /> SAN JOAOUlN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES I 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 Addresstl —' �M � City - Lot Size 15 � PM <br /> Owners Name Address Phone <br /> z <br /> Contractor's Name License No. Phone <br /> TYPE OF WELL/PUMP: NEIN WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 1 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 /> r ❑ Industrial El Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> Li Domestic/Private El Gravel Pack C1 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 /> I Repair Work Done ❑ Type of Pump H.P. — State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filter Material (Below 501 <br /> i TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> l available within 200 feet.) <br /> Installation will sere: Residence_ Commercial Other t <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg 1 Capacity No. Compartments <br /> PKG. TREATMENT PLT. L7 A Method of Disposal <br /> j r Distance to nearest- c. Well Foundation Property Line <br /> l <br /> I _ <br /> a LEACHING LINE ❑ No. & Length of lines '-Total length/size <br /> FILTER BED ❑ Distance to nearest: Well -Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> 1 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. I <br /> I 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." Contractors 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 /> I The applicant must call for all required inspections. Complete drawing on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT USE ONLY _ µ <br /> i <br /> Application Accepted by Date Area <br /> 1 Pi;or Grout Inspection by Date FinI al Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-Ml ❑ Lodi 3W3621 ❑ Manteca 823-7104 ❑ Tracy 835-638.5 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CA$H RECEIVED BY DATE PERMIT"No. <br /> y INFO <br /> K � J, y� <br /> .}+ Eli 1324 tREV.10181 / •�$ "g-1 1 0116Sj ata <br />