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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICTN <br /> 1601 E. HAZELTON AVE.,,STOCKTON, CA <br /> Telephone {209} 466-6781 I <br /> PERMIT EXPIRES 1 YEAR FROM DATE"ISSUED <br /> iComplete 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. I' fF, .kr , t � :.c" , I <br /> . t:' <br /> Job Addressc Ci Lot"Size_ PM <br /> Owner's Name + Address" ~D� M Phone f <br /> Contractor Address License No. Phone <br /> TYPE OF WELL/PU NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMEJhL5TALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK W_ER LINES DISPOSAL FLD- "PROP- LINE <br />` FOUNDATION AGRICUL OTHER WELL I-PITS/SUMPS <br /> I INTENDED USE TYPE OF WELL PROBLEM A CTION 5 TIONS <br /> i ❑ Industrial ❑ Open Bottom anteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gra c ❑ Tracy Type of Casing fications <br /> ❑ Public Other ❑ Delta Depth of Grnut Seal Type of t <br /> ❑ Irrigaf I�pprox. Depth ❑ Eastern Surface.Seal Installed by—"--.' t - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Weld Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50') <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION (No septic system permitted if public sewer is <br /> II' available within 200 feet.) <br /> Installation will serve: Residence_ Commercial Other <br /> Number of living units: II Number of bedrooms <br /> Character of soil to a depth'6f 3 feet: Water table depth <br /> SEPTIC TANK ❑ TypelMfg Capacity No. Compartments <br /> { PKG. TREATMENT PLT. ❑ 'f. Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ 'No. & Length of lines Total length/size <br /> FILTER BED ❑ ,Distance to nearest:" Well Foundation Property Line <br /> SEEPAGE PITS ❑ kIlpepth Size Number <br /> SUMPS Li "113istance to nearest: i Well - Foundation Property Line <br /> DISPOSAL PONDS ❑ �! M <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 Sin 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 /> I -erhploy 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: "f 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." Ii <br /> The applicant must all for allll required inspections. Complete drawing on averse side. I <br /> Signed ! _ Title: Date: <br /> F DEPARTMENT USE ONLY ��yy <br /> Application Accepted by Date �� Area IJ <br /> 0.Pit or Grout Inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ❑ Stk 466-6781 ❑ L68 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 /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED BY DATE PERMIYNO. <br /> ` INFO <br /> + EH 13-24 IREV. /A 57 1f0 �s - <br /> EH 14-26 b,/ - <br />