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APPLICATION FOR PERMIT - <br /> .e SAN JOAQUIN LOCAL HEALTH DISTRICT �t <br /> 1601 E. HAZETON AVE., STOCKTON, CA ` <br /> Telephone (209) 466-6781 ( _ <br /> PERMIT EXPIRES TYEAR 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 AddressCi <br /> � /Sa <br /> t Lot Size 2 pM <br /> Owner's Name all <br /> ! d <br /> dress��,,�y Phone ' <br /> Contractor Address 4` '""' License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ElDESTRUCTION [IL <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTU ELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PRO EM A CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ a Dia. of Well Excavation Dia. of Well Casing <br /> 11 Domestic/Private Elck Gravel PaTracy Type of Casing Specifications <br /> M Public ❑ Other Ll Delta Depth of Grout Seal Type of Grout <br /> I I Irrigationi-App Depth I I Eastern Surface Seal installed by <br /> Repair Work Done E Type Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth I Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIR/ADDITION l 1 DESTRUCTION Wo septic system permitted if public sewer is � <br /> i available within 200 feet.) <br /> Installation•will-serve:- Residence_ Commercial_� Other F <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of 3 feet:l Water table depth y <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments n I <br /> PKG. TREATMENT PLT. ❑ Method of Disposal �J <br /> Distance to nearest: Well Foundation Property Line r a <br /> LEACHING LINE ❑ No. & Length of lines <br /> Tota! length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> F <br /> SEEPAGE PITS I I Depth Size Number <br /> SUMPS L1 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ O . <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 shalt no <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 persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant mus II for all required " pection Complete drawing on reverse side. <br /> Signed X Title: <br /> Data: <br /> FOR DEPARTMENT USE ONLY ff <br /> Application Accepted by Date 9 2"1 Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca '823-7104 ❑ Tracy 835-6385 <br /> Applicant - Return all copies to: Environ ental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY <br /> /J CASH DATE PERM;IT;'NO.EH1 -211REV.r/K51EH 114 b <br /> -28 <br />