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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON 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/pum and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size Ag= PM <br /> Owner's Nam Address - Phone 7 — <br /> Contractor's Nam � License No. A51, a Phone <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 P 1 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS Q <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 /> D Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by R <br /> !i <br /> Repair Work Done D Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (B low 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION # DESTRUCTION ❑ (No septic system permitted if public sewer is ( <br /> available within 200 feet.) <br /> Installation will serve: Resi ence_ Commercial e 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. ❑ , Method of Disposal <br /> Distance t earWell ndation Pro erty Line <br /> LEACHING LINE T�L/No. & kaaLoflfines -leTotal length/size Q <br /> FILTER BED D Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 4;1,-�epth �?� Size Z.5 Number <br /> SUMPS ❑ Distance to nearest: Well Foundation 4,_000?4/ Property Line <br /> DISPOSAL PONDS D <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. <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, 1 shall not <br /> employ any person in such manner a come subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:"I certi a pert ce of the work for which this permit is issued,I shall employ persons subject to workman's co <br /> tion laws of California." <br /> The applicant must inspections. Complete drawing on rever <br /> r . <br /> Signed - -- Title: Date: <br /> FORD RT <br /> T USE ONLY I <br /> Ap icaAc Accepted by > Date 5`1 Area �— <br /> Pit or Grout Inspection by Date Final Ins ection by Date �7/ <br /> Additional Comments: ' r GG' <br /> ❑ Stk 466-6781 ❑ Lodi -3621 IT Mant ca -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 CASH RECEIVED BY DATE �{ PERMIT`N0. <br /> + EH13-241REV.10/831 `�v> '" �' <br /> EH 1126 <br />