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t <br /> w` APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT NO <br /> 1601 E. HAZELTON AVE.; STOCKTON, CA C <br /> Telephone (209) 466-6781 %C) Q � om\ <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> U ars(Complete in Triplicate) ' to <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or in 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, r G, <br /> Job Address of Size <br /> PM <br /> Owner's <br /> � Phone <br /> Cot ct © Address v�V License No. Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ <br /> DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ POSAL FLOTHER EJ TO NEAREST: SEPTIC TANK- SEW INES D. PROP. LINE <br /> FOUNDATION AGRICULT WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA COI CTION SPECIFICATIONS <br /> C] Industrial ❑ Open Bottom ❑ Manteca ia. of ell Excavation Dia. of Well Casing , <br /> ❑ Domestic/Private ElGravel Pack ElTracy Type 'ng— <br /> n of Ca ' <br /> 9 Specifications <br /> ❑ Public [IOther ❑ Del Depth of Gro Seal Type of Grout <br /> Irrigation <br /> ---Approx. Depth astern Surface Seal Ins lied by <br /> Repair Work Done LJType of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> hrt Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK:' NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTIO (No septic system permitted if public sewer is <br /> available within 200 feet,l <br /> Installation will serve; Residence_ Commercial_ Other <br /> Number of.-living units:. Number of bedrooms <br /> Character of soil to adepth of 3 feet: Water table depth , <br /> SEPTIC TANK ,g b Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ 1 <br /> t Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> e , <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> I <br /> SEEPAGE PITS ❑ Depth j Size Number <br /> SUMPS ❑"'Distance-to nearest: Well Foundation Property-Line <br /> DISPOSAL PONDS ❑ <br /> I;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, 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,'p <br /> icant must II for all required i flections. Com ete drawing on reverse side. <br /> Signed tle: _ Date: �" <br /> _{ r ENT USE ONLY r <br /> Application Accepted by _ — Date <br /> Pit or Grout Inspection by Date Final Inspection by y Dat-L <br /> Additional Comments: <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 C RECEIVED BY DATE PERMIT NO. <br /> + EH14-241REV.i/a51 LJrU� <br /> EH 1428 /' <br />