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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 II <br /> L� 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. �[ i <br /> City <br /> LA--r'TzW Lot Size /�� PM <br /> Job Address <br /> f` (� Phone <br /> Owner's Name , r �" Address3.3_, <br /> Contractors -- <br /> ' Address License No. Phone <br /> TYPE OF WELL/PUMP: _ NEW WELL 1-1WELL REPLACEMENT EJ DESTRUCTION ❑ <br /> PU INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC SEWER LINES DISPOSAL FLQ. PROP, LINE <br /> FOUNDATION <br /> ULTURE WELL OTH LIMPS <br /> „ <br /> INTENDED USE TYPE OF WELL , PROBLEM AREA C SPECIFICATIONS Dia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Man Dia. of Well Excavation <br /> Tracy Type of Casing --`-—Specifications. <br /> ❑ Domestic/Private ❑ Gravel Pack Type o t a <br /> f`I Public I=1 Other CI Delta Depth of Grout Seal �} <br /> I I Irrigation _.-Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work done Type of Pump <br /> H P State Work Done _ <br /> Well Des on ❑ Well Diameter Sealing Material Itop 501 <br /> Depth Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRlAODITION l I DESTRUCTION (No s Atticle systemhin refined it public-sewer is- <br /> avaInstallation will serve: Residence— Commercial'— Other <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character,of soil to a depth of 3 feet: <br /> ,. <br /> Capacity No. Compartments <br /> SEPTIC TANK ❑ 'Type/Mfg <br /> Method of Dispose! <br /> PKG. TREATMENT PLT. ❑ <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE LINo. & Length of lines Total length/size ; <br /> FILTER BED LJDistance to nearest: Well Foundation Property Line k <br /> 'q <br /> SEEPAGE PITS f I Depth Size Number <br /> SUMPS Cl Distance to nearest: Well Foundation Property Line <br /> I 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 /> r fy that in the performance of the work for which this permit is issued, I shall not <br /> Home owner or licensed agent's signature certifies the following: "I certi <br /> f employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature F <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 ust call for all req d inspections. Complete drawing on reverseside. ` <br /> Signed <br /> Title: �/ J Date: <br /> ' <br /> FOR DEPARTMENT USE ONLY r <br /> Date r ,J Area-- .— <br /> Application Accepted by <br /> Pit or Grout InspectionDate Final Inspection by Dat <br /> ' om <br /> C <br /> Additional Comments: <br /> 4l Com 1 ❑ Lodi 369-3621 © Manteca 823-7104 ❑ Tracy 535-6385 <br /> [It <br /> Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Sox 2009, Stk., CA 95201 <br /> !I <br /> FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. <br /> INFO C! / <br /> + EH 13-24(REV.1 i n 5) �c]� � � Qn <br /> 1 EH 14-2e <br />