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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 r <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 /> x / <br /> Job Address City Lot Size PM <br /> Owner's Name <br /> 0 Address Phone <br /> Contractor " VAddress L icense No. Phon <br /> Y TYPE OF.WELL/PUMP: NEW WELL 1-1WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> - PUMP INSTALLATION D 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 ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack , ❑ Tracy Type'of Casing Specifications <br /> Type Grout <br /> l"7 Public ❑ Other ❑ Delta _ Depth bf Grout Seal yp - NIZI <br /> I 1 I(rigation-- --Approxi-.Depth •I I Eastern Y surface Seal installed by - <br /> Repair Work Done ❑ Type of Pump H.P. + State Work Done <br /> Well Destruction ❑ Well Diameter Sealing..Material-ltop,50') <br /> Depth # Filler Material t6elo 'l — <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I'] tREPAIR!ADDITION LV DESTRUCTION I i INa ailaeptic systemthin rented if public sewer is <br /> Installation will serve: Residence# Commercial *.,. Other <br /> i <br /> Number of living units: Number of bedrooms ' <br /> Character of soil to a depth of 3 feet:' Water table depth <br /> SEPTIC TANK ❑ Type/Mfg - ti Capacity No. Compartments . <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> t <br /> Distance to.nearest-_-,Well Foundation Property Line <br /> y <br /> LEACHING LINE ❑ No. & Ler gth of lines t Total lengthlsize <br /> FILTER BED E] '" <br /> Distance to nearest: We11Foundation / Property Line <br /> i <br /> SEEPAGE PITS I I Depth / Sizerr���' -Number <br /> SUMPS Ll Distance Distance to nearest: WeiFoundation_.L� 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 far 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 call for all a u'red inspections. Complete drawing on r side. <br />'i Signed X Title: �f Date: <br /> i , <br /> FOR DEPARTMENT USE ONLY <br /> //%`' • Date 7 .- Area <br /> Application Accepted by q�} <br /> Pit or Grout Inspection by Date Final Inspection by �• Date <br /> P ! <br /> Additional Comments: <br /> iii ❑ Stk 466-67131 ❑ Lodi 369-3421 ❑ Manteca 823-7104 ❑ Tracy 835-6386 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 <br /> It <br /> FEE AMOUNT DUE AMOUNT REMITTED CK It CASH RECEIVED BY DATE PERMIT'NO. <br /> INFO <br /> EH 13-24(REV.f/H 5) ';}+ <br /> 4 EH 14-26 <br />