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APPLICATION FOR PERMIT <br /> SAN JOAQUiN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE TON AVE., STOCKTON, CA �- _•_4 ,41 <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 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 Address f City Lot Size PM <br /> Owner's Nam r Phone 1 75 71 <br /> r <br /> Contractor Address License No. Phone <br /> TYPE OF WE L/PUMP NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ 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 /> '-Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material {top 501 <br /> 1 <br /> } Depth Filler Material (Below 501 <br /> •TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION iNo septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ED—I Method of Disposal i <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑:I_No. & Length of lilies Total length/sizer <br /> FILTER BED '❑ Distance to nearest: Well Foundation Property Line <br /> IF 'T. "S <br /> S. <br /> SEEPAGE PITS X Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> hereby certify that 1 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 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: "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 appnK;==25=TitIe: <br /> awing on reverse side. / <br /> Signed � � Date: i�,...=itz_ <br /> n t, FOR DEPARTMENT USE ONLY' 2 `] <br /> Application Accepted by date �.7—I Area <br /> Pit or Grout Inspection ;7ate Final Inspection by Date g <br /> 'I 1 <br /> Additional.Comments. re li I e { -7_75- 3i,9" i <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> FEE INFO AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT"N0. <br /> + EH 1324[REV.i i e 5Y <br /> EH 14-28 SV. GCRj �/ <br />