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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE i 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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. f <br /> �"� �� l+ae City � ' Lot Size A' ' PM <br /> Job Address � <br /> Owner's Name ✓ Address Phone <br /> fts � <br /> Contractor LiceO nse No. 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 DISP L FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL �O HER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL s PROBLE A CONSTR_VC•-T O SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Well Excavation Dia. of Well Casing <br /> 1-1 Domestic/Private ❑ Gravel Pack ❑ Tracy Type o ing T Specifications <br /> 1-1 Public Cl Other n Delta Depth of Grout Type of Grout <br /> --- <br /> I I Irrigation _.-Approx. Bepth I I Eastern Surface Seal Installed by _ <br /> Repair Work Done ❑ Type of Pumpjf' �' H.P. State Work Done _ <br /> Well Destruction ❑ Well DiameteSealing Material (top 50') <br /> Depth Filler Material (Below 501 ` <br /> TYPE. OF SEPTIC WORK: NEW INSTALLATION i I REPAIR/ADDITION I I DESTRUCTIONPQNc.septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other <br /> Number of living units: Number of bedrooms 0 <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 to nearest: Well Foundation Property Line { <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 1-1 Depth Size Number <br /> SUMPS 0 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 C) <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 <br /> ompensation laws of California." <br /> The applica ust call for-all requiredspections. Complete drawing on reverse side. <br /> Signed X ��y Title: Date: <br /> FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date �~ Area <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ,10 Tra 835-6385 <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 •E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201FEE <br /> ' <br /> INF=O AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT-NO. <br /> ♦ EH13-24{REV.riKs1 � ��. 1 <br /> EH 14-2e <br />