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M 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 incompliance with San Joaquin County Ordinance No. 54 for sewage or No. 1862 for weVpump and the Rules and Regulations of the San Joaquin <br /> Local Health District, p�}� <br /> Job Address City Lot Sizt PM <br /> Owner's Name Address Phone <br /> Contractor. Address License No �� Phone w <br /> ^,i <br /> TYPE OF WELL/PUMP`. NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> I� PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> :IM FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Q Industrial ❑ Open Bottom El Manteca Dia. of Well Excavation Dia. of Well Casing <br /> O Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> Fl Public LI Other f-] Delta Depth of Grout Seal Type of Grout Y <br /> 1 1 Irrigation --Approx. Depth I i Eastern Surface Seal Installed by Or{ <br /> Repair Work Done ❑1 Type of Pump H.P. State Work Done _ 1 <br /> Well Destruction ❑� Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION IV REPAIR/ADDITION I I DESTRUCTION l I (No septic system permitted if public sewer is <br /> r I available within 200 feet.l /p <br /> Installation will serve: Residence L Commercial_ Other l <br /> Number of living units: Number of bedrooms (3 <br /> Characterof soil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ f Method of Disposal <br /> Distance to nearest: Well 100-4L-Foundation Property Line 6FO - .{ <br /> 1. <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foun ation a Property Ling-, <br /> SEEPAGE PITS r I I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well yy Foundation Property Line <br /> f DISPOSAL PONDS <br /> I hereby certify that I have prepared this application and that thework will be done in accordance with San Joaquin county ordinances, state laws, and t <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 shalt not <br /> employ any person in such manner as to become subject to workman's compensation laws of California."Contractors hiring or sub-contracting signature <br /> certifies the following:i'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.h �'� <br /> The applicant ust call for a uired pedtions. Compl a drawing o reverse side. <br /> 7 <br /> Signed X Title: Date <br /> N <br /> a FOR DEPARTMENT USE ONLY <br /> Application Accepted .� MIA Date �� S 4I Area - <br /> or Grout Inspection by Final Inspection by to `' <br /> C Additional Comments'' <br /> ❑ 5tk 466:6781 I ❑ Lodi 369-3621 ❑ Manteca 823-7144 C1 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 <br /> INFO I� AMOUNT_DUE AMOUNT REMITTED CASH RECEIVED BY DATE PERMII'T"NO. <br /> + EH 13-24{REV.i i n 51 � /���` <br /> EH 14-28 <br /> i <br />