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APPLICATION FOR PERMIT' <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT ' <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone 1209) 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 Address City Lot Size PM <br /> Owner's Name Address Phone <br /> Contractor's Name a No. _ phone <br /> TYPE OF WELL/PU P: NEW ELL ❑ WILL REPL CEME T ❑ I DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ 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 /> 4w <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing 'r Specifications <br /> ❑ Public ❑ Other ❑ Delta Depth of Grout Seal <br /> Type of Grout <br /> ❑ Irrigation ---4pprox!15epth '710 Eastern Surface Seal InstalleedFby <br /> Repair Work Done �❑ Type of Pump H.P. _` ` State Work Donees <br /> Well Destruction ❑ Well Diameter �Sealing Material,tog 501 <br /> ' Depth Filler Material CBelpw k) <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION REPAIR/ADDITJON`❑...DESTRUCTION ❑ (No septic system permitted if gublic sewer is <br /> 4 . .f 'available within 200 feet.) <br /> Installation will serve: Residence—4-;./Commercial_ Other <br /> 1 <br /> Number of living units: Number of ed rooms + <br /> Character of soil to a depth of 3 feet: _ Water table depth <br /> SEPTIC TANK ype/Mfg �lh/l 'r – Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ c Method of Disposal <br /> ;� <br /> Distance to nearest: ,Well ation 19 Property Line <br /> LEACHING LINE '" No. & Length of lines Total,length/size <br /> FILTER BED ❑ Distance to nearest: Well d o VE Property Line <br /> s <br /> SEEPAGE PITS l ❑ Depth i Number <br /> SUMPS Il 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'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 s c f I re u' ions Complete dra 'n n rev de. y <br /> Signed Date- <br /> FO IR <br /> ate:FOR DEPARTMENTPSEONLY <br /> Application Accepted by r �t�►? r�""� Date / L4 u 7 Ar a <br /> Pit or Grout Inspection by Date _._ Final Inspection by Date <br /> Additional Comments; <br /> ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., Box 2009, Stk., CA 95201 <br /> 4 \\ <br /> FEE <br /> INFO AMOUNT DUE AMOUNT REMITTED CASH CK RECEIVED 13Y� DATE PERMIT"NO. <br /> + EH 13-24(REV.10t83) <br /> EH 14-26 lig-Li A <br /> r <br />