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APPLICATION FOR PERMIT S , <br /> SAN JOAQUIN LOCAL.HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE.,fSTOCKTON, CA � <br /> Telephone {209} 466-6781 <br /> i <br /> ` PERMIT EXPIRES 1 YEAR.FROM DATE ISSUED - .�4 ,o <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 /> I Local Health District. <br /> Mt .v s-r a x4 ' <br /> Job Address { 1 <br /> City *Lot Size "� , <br /> u i fi Q. PM <br /> Owner's Name Address Phone <br /> B. <br /> Contractor " Address <br /> License Na. Phone <br /> TYPE OF WELL/PUMP: NEW WELLA ElWELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 10 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 fPROBL'EM AREA : CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial ❑Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracey Type of Casing Specifications <br /> ❑ Public 00'Other ❑ Delia Depth of Grout Seal Type of Grout <br /> ❑ Irrigation �4pprox. Depth L❑ Eastern. Surface Seal Installed by <br /> - - - <br /> Repair Work Done ❑ of-PumpH.P. _ State W77- <br /> Type <br /> e <br /> Well Destruction L, Well 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 /> available within 200 feet.) <br /> i Installation will serve: Residence— Commercial_ Other <br /> Number of living units: Number of bedrooms <br /> Character of soil to a depth:of 3 feet: Water table depth <br /> II SEPTIC TANK ❑ T <br /> k ype/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ i <br /> Method of Disposal <br /> Distance to nearest: t Well Foundation Property Line <br /> e <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> i FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> r SEEPAGE PITS ❑ Depth Size Number <br /> SUMPS <br /> ❑,. Distance to nearest: Well - „Foundation =- PropertyLine <br /> DISPOSAL PONDS El <br /> I hereby certify that I have prepared this application and that the wok 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 liensed agents 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."Contractors 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 mu II required inspections. Complete drawing on reverse side. <br /> I <br /> Signed X Title: � <br /> s <br /> Date: <br /> r R DEPARTMENT USE ONLY <br /> Application Accepted by c <br /> Date Area 0 <br /> Pit or Grout Inspection by Date <br /> i Final Inspection:by Date <br /> Additional Comments: <br /> ❑ Stk 466-6761 ❑.Lodi 369-3621 ❑ Manteca 623-7104 ❑ TrBcy 835-6385 <br /> M <br /> Applicant- Return all copies to: Environmental Health Permit/Services.16015 E. Hazelton Ave., P O. ox 2009, Stk., CA 95261 <br />' FEE AMOUNT DUE AMOUNT REMITTED CA H RECEIVED BY DATE PERMIT NO. <br />` INFO _ <br /> + EH13-24rREV.r/a5Y 3�'«a� <br /> EH 14-26- ALJ <br />