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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZEL I ON AVE., STOCKTON, CA n� <br /> Telephone (200) 466-6781 `�-- <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br /> # i <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 /> f <br /> City Lot Size PM <br /> Job Address — <br /> !c Address Pho <br /> Owner's Name <br /> x Address <br /> u !I Kicense Phone �y� <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ` <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR C1 OTHER <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES <br /> DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> { INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS pia. of Well Casing <br /> ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation <br /> Specifications <br /> ' ❑ Domestic/Private El Gravel Pack El Tracy Type of Casing Type of Grout —01 <br /> lPublic L1 Other a ❑ Delta Depth of Grout Seal YPe <br /> ❑ Irrigation --Approx. Depth ❑ Eastern Surface Seal Installed by 6 <br /> Repair Work Done ❑ Type of Pump <br /> H.P. State Work Done <br /> Well Destruction ❑ Weil Diameter Sealing Material (top 50') <br /> Depth Filler Material (Below 50'1 <br /> TYPE OF SEPTIC WORK: 'NEW INSTALLATION ❑ REPAIR/ADDITION C3DESTRUCTION iNo sepeiwshtem perfretted if public sewer is <br /> Installation will serve: Residence, Commercial, Other / <br /> Number of living units: Number of bedrooms <br /> Water table depth <br /> Character of soil to a dept of 3 feet: >' <br /> C <br /> SEPTIC TANK Type/Mfg apacity No. Compartments <br /> Method of Disposal <br /> PKG. TREATMENT PLT. Cl.. . <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 ❑ Depth Size Number <br /> SUMPS ❑ Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS <br /> rk will be done in accordance with San Joaquin county ordinances, state laws, and <br /> I hereby certify that I have prepared this application and that the wo <br /> rules and regulations of the San Joaquin Local Health District. <br /> ertify 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 c <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 Califor 'a.,, <br /> The applicant m s call for all required ins ons. mplete drawing on r se sid !� <br /> Title: Date: <br /> x Signed. <br /> FOR DEPARTMENT USE ONLY t <br /> - Date <br /> Appli a' n Accepted by qq q <br /> Pit or Grout Inspectio Date <br /> Final Inspection by Dated oJiJ <br /> Additional Comments: s <br /> ❑ Stk 466-6761 ❑ Lodi 369-3621 11 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 RECEIVED BY DATE PERMIT NO . <br /> INFO <br /> + EH 13-244REV.5/85S <br /> EH 1426 <br />