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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON ON AVE., STOCKTON, CA [VD <br /> Telephone (209) 466-6781 _#W � <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 /> ` City Lot Size PM <br /> Job Address` <br /> A�� AddressJW.-f__ Phone <br /> Owner's NamJ&License <br /> PhonContract Addr No <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION Ll <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 /> s <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECT <br /> Dia. of Well Casing <br /> ❑ Industrial LJOpen Bottom ❑ Manteca Dia. of avation <br /> Specifications <br /> EJ Domestic/Private EJ Gravel Pack ❑ Tracy ype of Casing *F p <br /> Public <br /> FI Depth of Grout Seal <br /> 1 1 Type of Grout <br /> I ! Irrigation _.Approx t 1 Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Pump H.P, State Work Done <br /> Well Destructio Well Diameter Sealing Material (top 50') A <br /> Depth Filler Material (Below 501 eVl, <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I1 REPAIRlADD1TION l I DESTRUCTIO fNo septic system permitted if public sewer is <br /> vailable within 200 feet.) <br /> Installation will serve: Residence— Commercial' Other <br /> Number of living units: Number of bedrooms_ r` <br /> IT <br /> Character of soil to a depth of 3 feet: Water table depth <br /> k s ' Capacity No. Compartments <br /> SEPTIC TANK ❑ Type/Mfg <br /> � Method of Disposal <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property-Line <br /> LEACHING LINE ❑ o.N & Length of lines Total length/size <br /> I <br /> FILTER-BED �. ❑ Distance to nearest: Well-r' Foundation Property Line <br /> SEEPAGE PITS t I Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that Ianhave prepared this application and that the work will be done in accordance with SJoaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Horne owner or licensed agent's signature certifies the to <br /> "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 /> The applicant ust call for all required inspections. Complete drawing on rev $e side. <br /> Signed X <br /> Title: — Date: �J <br /> FOR EPARTMENT USE ONLY ir= <br /> Application Accepted by Date <br /> Date Final I spection by Date <br /> Pit or Grout Inspection by T 4 <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi M-3621 ❑ Manteca 132377104; ❑ 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 /> Y <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED By DATE PERMIT NO. <br /> INFO <br /> ♦ EH 13-24 iREV.1 i n 51 <br /> ° EH 14-28 <br />