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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZELTON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 i <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. l <br /> Job Address 4 <br /> City 5 1 Lot Size PM <br /> Owner's Name J Phone <br /> t- _ j� i <br /> 3 o d Phone <br /> Contractor Address License filo. r <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLO- PROP, LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> i <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> ❑ Industrial D Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing <br /> D Domestic/Private ❑ Gravel Pack D Tracy Type of Casing Specifications <br /> I'1 Public ❑ Other L7 Delta Depth of Grout Seal Type of Grout--_ <br /> I <br /> rout _- <br /> I I Irrigation —..Approx. Depth l I Eastern Surface Seal Installed by - <br /> Repair Work Done ❑ Type of Pump H.P. State Work Done <br /> Well Destruction ❑ Well Diameter Sealing Material (top 501 <br /> Depth Filler Material (Below 501 - <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I.I REPAIR/ADDITION I I DESTRUCTION system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will serve: Residence_ ommercial� Other <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 Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> f � <br /> LEACHING LINE 0 No. & Length of lines Total length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS 11 Depth Size j Number <br /> SUMPS ❑ Distance to nearest: Well Foundation j 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 Di"strict. 2 <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 i-6such manner as to become subject to workman's compensation-laws of California." Contractor's hiring or sub-contracting signature <br /> c re following: "I rtify that in the performance of the work for which thispermitis issued,1 shall employ persons subject to workman's compensa- <br /> tio ws o aiifornia.' <br /> The appGcan ml cal r 5111,,eq r - pie raw ing evars <br /> 0 <br /> Signe e: _ Date: <br /> OR PARTMENT USE ONLY <br /> Application Accepled by Date Area <br /> f <br /> Pit or Grout inspection by Date Final Inspection by Date <br /> Additional Comments: <br /> ­0 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., P.0..9ox 2003, 51k., CA 95201 <br /> - e r <br /> FEE CK RECEIVED BY DATE PERMIT'NO. <br /> 16MOUNT DUE AMOUNT REMITTED <br /> INFO O CASH <br /> +,EH 13-24 I REV.)/x 57 J '- 29 � O <br /> FH 10-28 <br /> I� <br />