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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <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 i <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 /> A <br /> Job Address 9cs- Cit <br /> Lot Size PM <br /> Owner's Name mul�;t <br /> ddress Phone + <br /> Contractor f Address c3 �� License o / Phon <br /> �d. <br /> TYPE OF WELL/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 <br /> �P 5/SUMPS I <br /> INTENDED USE TYPE OF WELL`"�yPh0I3LEM AREA" CONStRUftON SPECIF_ ONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well E ion Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Casing Specifications <br /> n Public n Other } n pelt Depth of Grout Seal Type of Grout <br /> I 1 Irrigation _.-Approx. Dept Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type: of p H.P. State Work Done <br /> Well Destruction ❑ Diameter Sealing Material (top 50') <br /> h t <br /> Filler Material (Below 501 <br /> TYPE OF SEPTIC WO N�FWVNINSTALLATION I.'j REPAIR/ADDITION I I DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet.) t 11 <br /> Installation will serve: Residence Commercial_ Other V <br /> Number of living unrts: 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. O <br /> —I--.---,_ — Method of Disposal <br /> Distance to nearest: Well Foundation Property Line sk <br /> �.. <br /> LEACHING LINE ❑ No. & Length of lines Notal length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS I 1 Depth Size ---=---N umber-; <br /> SUMPS L-i Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ �! <br /> 1 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. fi <br /> : "I certify that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following <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 /> ,I r <br /> The applica ust call for all requir inspections. Complete drawing on reverse side. <br /> Signed I Title: <br /> i Date: <br /> I F' UEPARTfil1ENT USE�ONLY <br /> Application Accepted by Date Area- <br /> Pit or Grout Inspection by ' Date inal Inspection by Date <br /> Additional Comments: <br /> El Silk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 4 <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 ASH RECEIVED BY DATE PERMIT-NO. <br /> INFO <br /> + EH 13-24 IAEV.I/ ' lt7�6q <br /> EH 14-M GtaY �•C,G <br />