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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> LG 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 52091 966-6781 <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 sewago or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. tl <br /> Job Address / � �� <br /> City Lot Size PM <br /> i <br /> Owner's Name ress _ <br /> Phone <br /> Contrractor Address License No"a�I <br /> �/Uzl Phone <br /> TYPE OF WELL/PUMP: JEW WELL WELL REPLACEME ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION SYSTEM REPAIR ❑ OTHER L1 <br /> DISTANCE TO NEAREST: SEPTIC TANK � � SEWER LINES DISPOSAL FLD. PROP, LINE foZ <br /> FOUNDATION AGRICULTURE WELL OTHER WELL,j!_ PITS/SUMPS , <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> D industrial D Open Bottom L7 Manteca Dia. of Well Excavation <br /> �� Dia. of Well Casing <br /> ❑ Domestic/Private Ll Gravel Pack C Tracy Type of Casing Specifications �� _ <br /> C"1 Pria f__1 Other f7 Delta Depth of Grout Seal � D` Type of Grout <br /> Irrigllation 11*9 Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done ;K Type of Pump H.P. . //) State Work Done <br /> Well Destruction D Well Diameter _ Sealing Material (top 50') <br /> Depth Filler Material (Below 501 _ <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION i I DESTRUCTION I I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ Commercial_ Other (W\ <br /> Number of living units: __ Number of bedrooms <br /> Character of soil to a depth of 3 feet: Water table depth (� <br /> SEPT-IC TANK 0 Type/Mfg Capacity No. Compartments U <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> � I <br /> LEACHING LINT= Ll No. & Length of lines Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation _ Property Line <br /> SEEPAGE PITS I 1 Depth Size Number <br /> SUMPS LI Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS Ll <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." <br /> The applicant must cal r all rred ins c ' ns. ompleto drawing,on reverse side. <br /> Signed X Title: Date: <br /> FOR DEPARTMENT SE ONLY <br /> Application Accepted by Date /' �' <br /> Area <br /> Pit or Grout Inspection bpolo Final Inspection by Data �5 ��✓' <br /> Additional Comments: <br /> ❑ Stk 466-6781 © Lodi 369.3621 0 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 AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY GATE PERMIT'NO. <br /> INFO CASH <br /> +.EH t3-24 WA <br /> EH 14-2e � , <br /> `l' <br />