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APPLICATION FOR PERMIT i <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT I <br /> 1601 E. HAZEL 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/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job AddressCity Lot Size PM <br /> r <br /> Owner's Nam Address dam,` - Phone <br /> r <br /> Contractor Addr s License No. Phone f <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> /DISTANCE 70 NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> V FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> +. INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> b Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications <br /> ❑ Public ' ❑ Other Q Delta Depth of Grout Seal Type of Grout <br /> s❑ Irrigation __Approx. Depth ❑ Eastern Surface Seal Installed by <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction. ❑_ . Well-Diameter -- - -Sealing Material {top 50'1`— <br /> Depth _ Filler Material {Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is r <br /> available within 200 feet.) <br /> Installation will serve: F Residence=4~ Commercial— Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth of-3 feet: r Water table depth <br /> L <br /> t SEPTIC TANK ❑ Type/Mfg + Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ < Method of Disposal <br /> t Distance to.nearest: Well Foundation Property Line <br /> t. <br /> LEACHING LINE Cl No. & Length of lines Total length/size <br /> FILTER BED. ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS a,a ❑ 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'slsignature 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." <br /> The applicanst call far all rouired'inspections. Con3plete drawing on reverse sive. <br /> t � ,. <br /> Signed X Title: Date: o' <br /> / FOR DEPARTMENT USE ONLY <br /> Application Accepted by Date a Area cis <br /> Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: Iz�Z!-x'25 A �l�g '0 ' <br /> Stk 466-6781 171Lodi 369-3621 ElManteca 823-7104 EJracy 5-6385 A� <br /> 3 'Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O.,Box 2009, Stk., CA 95201 !"' o <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> + EH 13-24(REV.i/H5) ( D-&7`s-r10 <br /> EH 14-28 ��\ / +C �V <br />