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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <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 AddressI.t <br /> * � . City Lot Size PM <br /> Owner's Name <br /> Address Phone <br /> ContractorAddress License No. Phone { <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ElPUMP INSTALLATION ❑ SYSTEM.REPAIR ❑ OTHER ❑ I <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 /> CIIndustrial E3Open Bottom EI Manteca Dia. of Well Excavation <br /> Dia. of Well Casing <br /> ❑ Do y esticlPrivate ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout v I <br /> D Irrigation ---Approx. Depth ❑ Eastern Surface Seal installed.by <br /> Repair�!Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Dtestruction 12 Well Diameter Sealing Material (top 50') y <br /> ! <br /> - Depth _ —__ Filler Material {Be ow 50'1 <br /> TYPEOF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITIO ESTRUCTI11 ON (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence?' Co mercial Other i <br /> Number of living units: Number of bedrooms <br /> Rs };, <br /> Character of soil to a depth of 3feet: Water table depth <br /> SEPTIC TANK E2Type).R) Capacity No. Compartments ; <br /> PKG. TREATMENT P T. ❑ ' <br /> � Method of Disposal <br /> D�stance,tornear_st: Well Foundation Property Line <br /> i <br /> LEAC SING LINE ❑ No. & Length of lines $ i <br /> Total length/size <br /> FILTER BED El <br /> R Distance ti nearest: Well Foundation Property Line <br /> SEEPAGE PITS Eli 'Depth Size N <br /> � } <br /> umber <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPdSAL PONDS ❑ i <br /> 1 herebycertifythat I have prepared.this application and that the work will be done in accorrdance 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 perforiance of the work for which this permit is issued, I shall not <br /> employ any pefson ain;such manner as to become subject to workman's compensation laws California."Contractor's hiring or sub-contracting signature t <br /> certifies the folloivi4g: "I certify that in the'performance of the work for which this permit is issued,)shall employ persons subject to workman's com <br /> tion la"ws of California." i pensa- <br /> The a�pliGant mustcalf for all required inspections. Complete drawing on reverse side. <br /> } <br /> Signe . Title:r r Date: <br /> FOR DEPARTMENT USE ONLY y <br /> Application Accepted by ` Date —e ^a ib <br /> r ( Final Ins` Area <br /> Pit or Grout'Ihspection - Date pection by���t'�-��-- Date /t7-dr9-��/, <br /> Additional Comments: - i <br /> ❑ Stk 466-6781 EI Lodi 369-3621$ ❑ Manteca 823-7104 ❑ Tracy 8356385 i <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 l AMOUNT REMITTED <br /> INFO CASH RECEIVED BY DATE PERMIT NO. <br /> + EH 1324fREV.1/8sl 413 <br /> S b0 <br /> EH 1428 <br /> T o� <br />