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APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZETON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES TYEAR 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 /> t 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 /> r <br /> Job Address <br /> S City of Size PM <br /> ( �Q+ _ Address UPhone <br /> Owner's Name-" " <br /> lAddress License No. Phone <br /> Contractor <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT FIDESTRUCTION <br /> PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHE 171 <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 r <br /> Specifications <br /> ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing S P <br /> f 1 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout <br /> i I I Irrigation —.-Approx. Depth t 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 Stop 501 <br /> Depth 7 Filler Material (Below 501 <br /> TYPE OF SEPTIC WORK: NE INSTALLATION I:i REPAIR/ADDITION I I DESTRUCTION I I (Noavasblpelwthine200 feeft}ed if public sewer is <br /> t.Installation will serve: Residence Commercial_ Other <br /> Number of living units: Numb of bedrooms <br /> Character of soil to a depth of 3 feet: Water t epth <br /> SEPTIC TANK ❑" Type/Mfg Capacity . Compartments <br /> PKG. TREATMENT PLT. ❑' Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> I <br /> i <br /> LEACHING LINE ❑ No. & Length of lines Total length/size <br /> r FILTER BED iO Distance to nearest: Well Fo ation Property Line <br /> I SEEPAGE PITS 1 ! DepthSize Number <br /> SUMPS Ll Distance to earest: Well Foundation Property Line <br /> f <br /> 1 y , <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 /> 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 California." <br /> The applicant t call f r all required in ti ns. Comp to drawing an reverse side. �} f '7 <br /> Signed Xy� � f Title: Date: I <br /> FOR DEPARTMENT USE ONLY 1 Q <br /> Application Accepted by Date r-� Area—/� <br /> Pit or Grout Inspection by ate Final Inspection by <br /> Additional Comments: y <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., P.O. Box 2009, 5tk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTEDASR RECEIVED BY DATE PERMIT NO. <br /> INFO <br /> r + EH 13-241REY.r/ws) 1 sem! '"[ C/_/y� � <br /> EH 14.26 v s, <br /> f <br />