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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T OIC AVE., STOCKTON, CA <br /> i <br /> Telephone (209) 466-6781 1 <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 Address / s ) �d Ce) City Lot Size PM <br /> Owner's Name .Address `"" Phone <br /> Contractors � Address L License No. 0 hone <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 <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom LJManteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack-' ❑ Tracy Type of Casing Specifications' <br /> 4 ' ` Type of Grout r <br /> f`I Public � f 1 Other C1 Delta Depth of Grout Seal YP ,t <br /> I I Irrigation _.Approx. Dep.th.t"'I I Eastam Surface Seal installed by - <br /> Repair WorkDone ❑ Type of Pump t H.P. State Work Done _ 1 <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 t <br /> C f <br /> j Depth x L Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION AIR/ADDITION l I DESTRUCTION I I (No septic system permitted if public sewer is <br /> # available within 200 feet.I <br /> Installation will serve: Residence Commercial Other ` 't <br /> Number of living units: _ Number of bed! ours... N <br /> Character of soil to a depth of 3 feet: Water table depth' <br /> SEPTIC TANK 9_--r,`pe/Mfg. Capacity � � No. Compartments - <br /> I ��; Disposal <br /> t _ <br /> PKG. TREATMENT PLT. [2Method of Dis W p <br />> Distance to nearest: Well Foundation'- to—Property—Line <br /> LEACHING LINE 0_9'_N`o. & Length of lines Total lengthlsi: <br /> t <br /> FILTER BED ) stance to nearest: Well�_ Foundation _._.. Property Line <br /> t <br /> SEEPAGE PITS f4-�epth !XX— -size_3� Number <br /> SUMPS L] [ <br /> Distance to nearest: Well� , Foundation_.._.62_,4 _ Property Line f <br /> DISPOSAL PONDS ❑ ` �. f l� <br /> 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. 1 <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 as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature <br /> c Mies 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 /> E tion la f Cal1forni . <br /> The applict. <br /> u ca fo 11 r uire I spe late drawing on reverse side / (� <br /> IZZ� 4, <br /> Signe <br /> Title: Date: C r9 <br /> I FOR.DEPARTMENT USE ONLY <br /> Application Accepted by Date _'� JArea I /C <br /> f i or Grout inspection by Date l -nal Inspection byDate r�� <br /> 1 � ; <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 /> I <br /> I FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO CASH <br /> r.EH 13-24(REV.1/11 5) <br /> EH 11-28 !! �° <br />